EPIDEMIOLOGIC TRENDS IN DRUG ABUSE

Proceedings of the Community Epidemiology Work Group

Highlights and Executive Summary

January 2007

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES NATIONAL INSTITUTES OF HEALTH

NATIONAL INSTITUTE ON DRUG ABUSE

Proceedings of the Community Epidemiology Work Group

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES NATIONAL INSTITUTES OF HEALTH Division of Epidemiology, Services and Prevention Research National Institute on Drug Abuse 6001 Executive Boulevard Bethesda, Maryland 20892

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EPIDEMIOLOGIC TRENDS IN DRUG ABUSE: HIGHLIGHTS AND EXECUTIVE SUMMARY

The National Institute on Drug Abuse (NIDA) acknowledges the contributions made by the representatives of the Community Epidemiology Work Group (CEWG) who prepare the reports presented at the meetings. Appreciation is extended also to other participating researchers who contribute information. This publication was prepared by MasiMax Resources, Inc., under contract number N01-DA-1-5514 from the National Institute on Drug Abuse. The information presented in this Executive Summary is from the Abstracts and PowerPoint slides prepared by 22 CEWG representatives for the CEWG meeting in San Antonio, Texas; tape recordings from the half-day

meeting; and the information provided through followup telephone conference calls in February. Data/information supplemental to the meeting presentations and discussions have been included in this report. All material in this volume is in the public domain and may be reproduced or copied without permission from the Institute or the authors. Citation of the source is appreciated. The U.S. Government does not endorse or favor any specific commercial product. Trade or proprietary names appearing in this publication are used only because they are considered essential in the context of the studies reported herein.

For more information about the Community Epidemiology Work Group and other research-based publications and information on drug abuse and addiction, visit NIDA’s Web site at http://www.drugabuse.gov. Both Volumes I and II (available in limited supply) can be obtained by contacting the National Clearinghouse for Alcohol and Drug Information by mail: by phone: by fax: P.O. Box 2345 Rockville, MD 20852-2345 (301) 468-2600 (800) 729-6686 (301) 468-6433

National Institute on Drug Abuse NIH Publication No. 07-6200 Printed August 2007

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Proceedings of the Community Epidemiology Work Group, January 2007

Foreword

This Executive Summary is a synthesis of findings from data prepared by CEWG representatives for the 61st semiannual meeting of the Community Epidemiology Work Group (CEWG) scheduled in San Antonio, Texas, on January 17–19, 2007, under the sponsorship of the National Institute on Drug Abuse (NIDA). Because inclement weather prevented many CEWG representatives and invited guests from traveling to the site, the meeting was shortened and included presentations on January 17 by eight CEWG representatives, a guest researcher from Latin America, and a representative of the Drug Enforcement Administration. However, all 22 CEWG representatives submitted data they had prepared for the meeting; later in February, they participated in followup telephone conference calls to discuss findings and issues. For the January 2007 meeting, representatives prepared 2006 half-year data and/or fiscal year 2006 data. The primary emphasis of the meeting and subsequent followup telephone conferences was on pursuing, discussing, reviewing, and providing updates on drug abuse issues that emerged at the June 2006 meeting and the 6-month period leading up to the January meeting. Through focused discussions at meetings, participants report on, share insight about, and review… • What has was learned about drugs patterns and trends and emerging drug problems from available data sources What was learned from local sources of information, such as key informants The emerging questions and issues that need to be addressed

CEWG areas. The findings are taken from the CEWG representatives’ Abstracts and PowerPoint presentations, from presentations at the meeting, and two followup telephone conference calls. Data/information supplemental to the meeting presentations and discussions has been included as appropriate. The report focuses on the abuse of cocaine/crack, heroin, opiates/narcotic analgesics (other than heroin), methamphetamine, marijuana, club drugs, phencyclidine (PCP), and benzodiazepines. An update on the emerging problems related to fentanyl and fentanyl mixtures in the United States is included in the section on Other Opiates/ Narcotic Analgesics. The information published after each CEWG meeting represents findings from CEWG area representatives across the Nation, which are supplemented by national data and by special presentations at each meeting. Publications are disseminated to drug abuse prevention and treatment agencies, public health officials, researchers, and policymakers. The information is intended to alert authorities at the local, State, regional, and national levels, and the general public, to current conditions and potential problems so that appropriate and timely action can be taken. Researchers also use the information to develop research hypotheses that might explain social, behavioral, and biological issues related to drug abuse.

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The information from the CEWG network presented in this report includes an overview of drug abuse patterns and trends in 22

Moira P. O’Brien Division of Epidemiology, Services and Prevention Research National Institute on Drug Abuse National Institutes of Health Department of Health and Human Services

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Contents

Foreword......................................................................................................... NIDA’s Public Health Division: The Division of Epidemiology, Services and Prevention Research Wilson M. Compton, M.D., M.P.E., Director ............................................................ The CEWG Network: Roles, Functions, and Data Sources ............................... Key Findings and Considerations for the June 2007 CEWG Meeting ................ Drug Abuse Patterns and Trends Across CEWG Areas Cocaine/Crack .................................................................................................. Heroin............................................................................................................. Other Opiates/Narcotic Analgesics ...................................................................... Methamphetamine ............................................................................................ Marijuana ........................................................................................................ Club Drugs (MDMA/GHB/GBL, Ketamine) ............................................................. Phencyclidine (PCP) .......................................................................................... Benzodiazepines/Depressants ............................................................................ CEWG Area Abstracts ...................................................................................... Recent Trends in Drug-related Emergency Department Visits from DAWN Elizabeth H. Crane, Ph.D., M.P.H. .........................................................................

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1 3 8

12 22 31 41 51 58 62 64 68

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Appendices Appendix A. Total Admissions, by Primary Substance of Abuse and CEWG Area: 2005–2006 ...................................................................................................... Appendix B-1. DAWN ED Samples and Reporting Information, by CEWG Area: January–June 2006........................................................................................... Appendix B-2. Numbers of Cocaine, Heroin, Methamphetamine, Marijuana, Methylenedioxymethamphetamine, Phencyclidine, and Lysergic Acid Diethylamide ED Reports in 12 CEWG Areas (Unweighted1): January–June 2006 ......................... Participants.....................................................................................................

95 96

96 97

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NIDA’s Public Health Division: The Division of Epidemiology, Services and Prevention Research

NIDA’S Public Health Division: The Division of Epidemiology, Services and Prevention Research
Wilson M. Compton, M.D., M.P.E., Director This presentation provides an overview of DESPR, its components (including the CEWG), objectives, recent findings, questions posed for 2006 and 2007, and new research opportunities. In addition to its epidemiology program, DESPR includes the Prevention Research Branch (PRB), the Services Research Branch (SRB), and the Community Epidemiology Work Group (CEWG). The primary goal of DESPR is to develop scientific knowledge that can be applied in public health policy and practice. Based on an integrated population-based approach and a public health orientation, DESPR supports research aimed at… • Understanding the interactions between individuals who abuse or are at risk for using drugs and their environments Assessing the continuum of problems and causes related to drug abuse Determining the most effective drug abuse prevention and treatment intervention methods Impacting public policy and practice at all levels (e.g., local State and Federal), including the financing of interventions that have proven to be effective Fostering and providing a guide for new research

Results produced by the Monitoring the Future survey updated the annual trends on drug use among young people (Johnston et al. 2005). It was reported, for example, that cigarette smoking among secondary school students had declined markedly since the mid-1990s. SRB-supported research provided a better understanding of the recovery and cost benefits of a life course approach to treatment (Zarkin et al. 2005). Such studies have provided an increased understanding of drug addiction as a chronic relapsing condition like other diseases (e.g., hepatitis). Based on randomized studies, PRB-supported researchers (Spoth et al. 2005) produced findings on the long-term effectiveness of brief partnership-based universal prevention interventions (e.g., school-based) with adolescent methamphetamine abusers. Studies showed that HIV screening can be as cost-effective as screenings for hypertension and other medical conditions (Paltiel et al. 2005; Sanders et al. 2005).

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The major DESPR research questions posed for 2006 included the following: • What new theoretical approaches can inform researchers? For example, what are the pathways to drug abuse? How can we assess co-morbidity as it relates to prevention and treatment intervention? What intrapersonal and environmental factors interact with each other and with genetic factors? Factors might include policies, laws, police enforcement, availability of drugs, and family factors. It is difficult to conduct such studies because of the potential interaction of different factors.

Each year, key findings produced by researchers supported by DESPR are reviewed. Some examples of recent efforts are as follows:

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EPIDEMIOLOGIC TRENDS IN DRUG ABUSE: HIGHLIGHTS AND EXECUTIVE SUMMARY

How can science and services be blended to measurably impact public health outcomes? For example, studies have shown that contingency management can be an effective treatment intervention.

NIDA has been placing more emphasis on a “network of networks” approach. The objective is to assist researchers in taking advantage of the infrastructures that have been established. This approach is designed to make maximum use of resources, especially during a period when funding is limited. The CEWG is a good example of an existing network because it is well-established, vigorous, cost-efficient, produces current data/information about drug abuse patterns and trends, and serves as an early warning system (identifying emerging drugs and drug problems) that could be of use to other researchers. Other networks include the Clinical Trials Network, Criminal Justice Network, and AIDS networks. There are challenges facing the CEWG and the need to maintain the early warning system. The Arrestee Drug Abuse Monitoring program was discontinued, and there have been reductions in the scope of metropolitan coverage in the Drug Abuse Warning Network. A critical question is: What can be done to supplement existing Federal and local data sources? Some CEWG areas have been more successful than others in accessing relevant data from local sources, and there is a need for opportunities for CEWG representatives to learn from one another, for example, on ways of accessing local Poison Control Center data and local medical examiner/coroner data. There is also the problem of assessing drug abuse trends when there is no verifiable denominator for a specific drug abuse indicator or in cases where, for methodological

reasons, data cannot be compared across time or CEWG area (e.g., as with DAWN Live!). Understanding drug abuse patterns and trends can be augmented by qualitative research. CEWG representatives can and do get anecdotal information from street contacts, key informants, and other qualitative research methods; such information increases understanding of changes in drug use over time. References Johnston, L.D.; O’Malley, P.M.; Bachman, J.G.; and Schulenberg, J.E. (2005). Monitoring the Future national results on adolescent drug use: Overview of key findings, 2004. (NIH Publication No. 055726). Bethesda, MD: National Institute on Drug Abuse. Paltiel, A.D., Weinstein, M.C.; Kimmel, A.D.; Seage, G.R.; Losina, E.; Zhang, H.; Freedberg, K.A.; and Walensky R.P. (2005). Expanded screening for HIV in the United States—an analysis of cost-effectiveness. New England Journal of Medicine 352(6):586-595. Sanders, G.D.; Bayoumi, A.M.; Sundaram, V.; Bilir, S.P.; Neukermans, C.P.; Rydzak, C.E.; Douglass, L.R.; Lazzeroni, L.C.; Holodniy, M.; and Owens, D.K. (2005). Cost-effectiveness of screening for HIV in the era of highly active antiretroviral therapy. New England Journal of Medicine 352(6):570-585. Spoth, R.L.; Clair, S.; Shin, C.; and Redmond, C. (2006). Long-term effects of universal preventive interventions on methamphetamine use among adolescents. Archives of Pediatrics & Adolescent Medicine 160: 876–882. Zarkin, G.A.; Dunlap, L.J.; Hicks, K.A.; and Mamo, D. (2005). Benefits and costs of methadone treatment: results from a lifetime simulation model. Health Economics 14(11):1133-1150.

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The CEWG Network: Roles, Functions, and Data Sources

Roles of the CEWG The CEWG is a unique epidemiology network that has functioned for nearly 31 years as a drug abuse surveillance system to identify and assess current and emerging drug abuse patterns, trends, and issues, using multiple sources of information. Each source provides information about the abuse of particular drugs, drug-using populations, and/or different facets of the behaviors and outcomes related to drug abuse. The information obtained from each source is considered a drug abuse indicator. Typically, indicators do not provide estimates of the number (prevalence) of drug abusers at any given time or the rate at which drug-abusing populations may be increasing or decreasing in size. However, indicators do help to characterize drug abuse trends and different types of drug abusers, such as those who have been treated in emergency rooms, have been admitted to drug treatment programs, or died with drugs found in their bodies.

Data on items submitted for forensic chemical analysis serve as indicators on availability of different substances and engagement of law enforcement at the local level, and data such as drug price and purity are indicators of availability, accessibility, and potency of specific drugs. Drug abuse indicators are examined over time to monitor the nature and extent of drug abuse and associated problems within and across geographic areas. In January–February 2007, researchers from 22 geographically dispersed areas participated in the CEWG meeting and/or telephone conference followup discussions. In addition to the information provided by the 19 sentinel areas that have served in the network for many years, guest researchers from Albuquerque, Cincinnati, and Maine provided data from their respective areas. The 22 participating areas are depicted in the map below.
Maine

Seattle Boston Minneapolis/ St. Paul New York Detroit Chicago Denver San Francisco Los Angeles Phoenix San Diego Albuquerque Texas Honolulu Cincinnati Philadelphia Baltimore Washington, DC

St. Louis

Atlanta

Miami/Ft. Lauderdale

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The Functions of CEWG Meetings The CEWG convenes semiannually. The interactive semiannual meetings continue to be a major and distinguishing feature of the CEWG. CEWG representatives and guest researchers present information on drug abuse patterns and trends in their areas through formal presentations, using PowerPoint slides to present graphic data. Personnel from Federal agencies provide updates of data sets used by the CEWG. Time is set aside for question and answer periods and discussion sessions. The meetings provide a foundation for continuity in the monitoring and surveillance of current and emerging drug problems and related health and social consequences. Through the meetings, the CEWG accomplishes the following: Dissemination of the most up-to-date information on drug abuse patterns and trends in each CEWG area Identification of changing drug abuse patterns and trends within and across CEWG areas Planning for followup on identified problems and emerging drug abuse problems Through ongoing research at State, city, and community levels; the interactive semiannual meetings; and e-mail, conference calls, and other exchange mechanisms, CEWG representatives maintain a multidimensional perspective from which to access, analyze, and interpret drug-related phenomena and change over time. At the semiannual meetings, CEWG representatives address issues identified in prior meetings, and, subsequently, identify drug abuse issues for followup in the future.

Presentations by each CEWG representative include a compilation of quantitative drug abuse indicator data. Many representatives go beyond publicly accessible data and provide a unique local perspective obtained from qualitative research. Information is most often obtained from local substance abuse treatment providers and administrators, personnel of other health-related agencies, medical examiners, poison control centers, law enforcement officials, and drug abusers. Time at each meeting is devoted to presentations by invited speakers. These special sessions typically focus on the following: Presentations by researchers in the CEWG host city Presentations by a panel of experts on a current or emerging drug problem identified in prior CEWG meetings Updates by Federal personnel on key data sets used by CEWG representatives Drug abuse patterns and trends in other countries Identification of changing drug abuse patterns is part of the interactive discussions at each CEWG meeting. Through this process, CEWG representatives can alert one another to the emergence of a potentially new drug of abuse that could spread from one area to another. The CEWG is uniquely positioned to bring crucial perspectives to bear on urgent drug abuse issues in a timely fashion and to illuminate their various facets within the local context through its semiannual meetings and postmeeting communications. Planning for followup on issues and problems identified at a meeting is initiated during discussion sessions at meetings, with postmeeting planning continuing through e-

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The CEWG Network: Roles, Functions, and Data Sources

mails and conference calls. Postmeeting communications assist in formulating agenda items for a subsequent meeting, and, also, raise new issues for exploration at the following meeting. Emerging/Current Trend is an approach followed at CEWG meetings since June 2003; this is a direct product of the planning at a prior meeting and subsequent followup activities. The Emerging/Current Trend at the January 2005 meeting featured a panel on methamphetamine abuse. The focus in the June 2006 meeting was on fentanyl and fentanyl mixtures. In June 2004, a special panel addressed the abuse of prescription drugs. In June 2003, a special panel was convened on Methadone-Associated Mortality, and, in December 2003, a PCP Abuse Panel addressed the issue of phencyclidine abuse as a localized emerging trend. The Emerging/Current Trend approach draws upon the following: CEWG representatives’ knowledge of local drug abuse patterns and trends Small exploratory studies Presentations of pertinent information from federally supported data sources Presentations by other speakers knowledgeable in the selected topic area The agenda for January 2007 meeting was patterned after previous CEWG meetings. However, because inclement weather prevented many CEWG representatives and guest researchers from traveling to the host city (San Antonio, Texas), the meeting was shortened and included presentations by eight CEWG representatives who provided updates on drug abuse patterns and trends in their areas. A guest researcher from the CICAD Inter-American Observatory on Drugs, OAS, Inter-American Drug Abuse Control Commission, provided information on drug patterns and trends in Latin America. An

official from the Drug Enforcement Administration focused on the emerging threats from abuse of prescription drugs, especially fentora (fentanyl buccal tablet) used in treatment for breakthrough pain in opioidtolerant cancer patients, and tramadol, also used in pain management. Abuse of fentora may lead to respiratory depression. Information that would have been presented by all CEWG representatives at the full meeting was available for inclusion in this publication. All 22 CEWG representatives provided copies of their PowerPoint presentations and Abstracts, and, in February, participated in telephone conference calls in which they discussed issues and provided additional information on drug abuse patterns and trends in their areas. Data/information supplemental to the CEWG meetings and discussions are included in this report. Primary sources of data used by the CEWG and presented in this Executive Summary are summarized below. Treatment data are from CEWG reports and represent statewide data for Arizona, Hawaii, Maine, and Texas, and metropolitan-area data for 16 CEWG areas. No recent data were available for Albuquerque and Washington, DC. Because the States of Illinois and California had not completed changes in their treatment database systems by the time of the January 2007 CEWG meeting, only 2005 data were available for Chicago, Los Angeles, and San Diego. Also, because Philadelphia data for 2006 did not distinguish between primary, secondary, and tertiary drugs of abuse, 2005 data were retained for Philadelphia to depict trends, by drug, over time. Five CEWG areas provided fiscal year (FY) 2006 data, one provided data for calendar year (CY) 2006, and 10 reported data for the first half of CY 2006. The various reporting periods for each CEWG area are depicted in Appendix A. The FY 2006 data from Cincinnati were not yet complete for the entire year,
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EPIDEMIOLOGIC TRENDS IN DRUG ABUSE: HIGHLIGHTS AND EXECUTIVE SUMMARY

and represent approximately 65 to 75 percent of the data for this city. The South Florida treatment data for the first half of 2006 were from nine Broward County Addiction Recovery Center (BARC) programs that serve 51.5 percent of admissions to county treatment facilities. Treatment data on primary abuse of specific drugs are reported as percentages of total admissions, excluding alcohol. Data on demographic characteristics (gender, race/ethnicity, age) and route of administration of particular drugs were provided for some CEWG areas. The number of admissions for alcohol and other drugs in the 2005–2006 time periods are presented for the 20 CEWG areas in Appendix A. Treatment data are not totally standardized across CEWG areas. Drug Abuse Warning Network (DAWN) emergency department (ED) data for 13 CEWG areas for the first half of 2006 were accessed through DAWN Live!, a restricted-access online service administered by the Office of Applied Studies (OAS), Substance Abuse and Mental Health Services Administration (SAMHSA). Participation by EDs in each DAWN sample was incomplete; completeness data are summarized in Appendix B-1. The percentages and unweighted numbers cited in this Executive Summary represent drug reports involved in drug-related visits for illicit drugs (derived from the category of “major substances of abuse,” excluding alcohol) and the nonmedical use of selected prescription drugs (derived from the category of “other substances.”) Drug reports exceed the number of ED visits because a patient may report use of multiple drugs (up to six drugs plus alcohol). Since all DAWN cases are reviewed for quality control, the data may be corrected or deleted, and, therefore, are subject to change. The numbers of DAWN Live! reports represent unweighted estimates of ED visits and cannot be compared across CEWG areas or across data collection years. A full description of the

DAWN system can be found at <http://dawninfo.samhsa.gov>. Local drug-related mortality data from medical examiners/coroners (ME/Cs) were reported for 17 CEWG areas. Five reported county-level data for selected drugs for the first half of 2006 (Broward County, Florida; Cincinnati/Hamilton County; Honolulu; Miami/Dade County; and Seattle/King County) and two reported for the first 9 months of 2006 (Detroit/Wayne County and Minneapolis/St. Paul [Hennepin and Ramsey Counties]). Philadelphia and St. Louis reported city-level data for the first half of 2006, and San Diego presented data on methamphetamine-related deaths in 2005. Recent statewide ME/C data were reported for Florida (first half of 2006) and for Georgia (FY 2006). Deaths involving fentanyl in 2006 were reported for the States of New York and Maryland. Colorado, Maine, and Texas data are for 2005. The New Mexico data represent age-adjusted rates per 100,000 population for drug overdose deaths in Albuquerque/Bernalillo County and the State of New Mexico for 2003–2005. Mortality data from all other sites represent the presence of a drug in a decedent and are not defined as overdose deaths. The mortality data are not comparable across areas because of variations in methods and procedures used by ME/Cs. Drugs may cause a death or simply be detected in a death, and multiple drugs may be identified in a single case, with each reported in a separate drug category. National Forensic Laboratory Information System (NFLIS) data are maintained by the Drug Enforcement Administration (DEA); these are reported for FY 2006 in 21 CEWG metropolitan areas and in Texas (statewide). The data are based on State and local forensic laboratory analyses of items received from drug seizures by law enforcement authorities. There are differences in local/State lab

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The CEWG Network: Roles, Functions, and Data Sources

procedures and law enforcement practices across areas, making area comparisons inexact. Also, the data cannot be used for prevalence estimates because they are not adjusted for population size. They are reported as the percentage that each drug represents in the total drug items analyzed by labs in a CEWG area. Law enforcement data include drug price data from the National Drug Intelligence Center (NDIC), U.S. Department of Justice (June 2006), and data on metham-

phetamine lab incidents from DEA’s National Clandestine Laboratory Database (updated October 2006). Also cited in this report are local data accessed and analyzed by CEWG representatives. The sources include local law enforcement (e.g., data on drug arrests); local DEA offices; High Intensity Drug Trafficking (HIDTA) reports; poison control centers and Helplines; local and State surveys; and key informants and ethnographers.

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Key Findings
Methamphetamine abuse indicators decreased in Atlanta in the first half of

2006, but they remained at relatively high levels. Indicators continued at low levels in all other 10 CEWG areas east of the Mississippi River. In areas west of the Mississippi, where methamphetamine indicators were higher, decreases were reported in four areas (Denver, Honolulu, Minneapolis/St. Paul, and St. Louis); increases were reported in five (New Mexico, Phoenix, San Diego, Seattle, and Texas); and indicators remained stable in two (Los Angeles and San Francisco). From 2002 to 2005, the numbers of clandestine laboratory incidents reported by the DEA decreased sharply in most CEWG States west of the Mississippi River. While lab incidents remained low in areas east of the Mississippi, there were dramatic increases in incidents reported in Florida, Ohio, Michigan, and Pennsylvania. Although methamphetamine abuse indicators decreased or remained stable in most CEWG areas, CEWG representatives expressed a growing concern about the… • Increased trafficking, availability, and abuse of higher purity methamphetamine (e. g., “ice,” “crystal”) from Mexico, reported in most CEWG areas • Increased indicators of methamphetamine abuse in different populations (e.g., youth, women, African-Americans, Hispanics)
Cocaine/crack abuse indicators remained stable in 19 CEWG areas and

increased in 3 areas (Honolulu, Maine, and New Mexico). Indicators continued to be lowest in San Diego (where methamphetamine indicators remain high). There were reports in some areas that… • Cocaine/crack indicators had increased among populations in which methamphetamine abuse indicators had decreased • Cocaine/crack abuse indicators increased in different populations (e.g., Whites, Hispanics)

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Key Findings and Considerations for the June 2007 CEWG Meeting

Heroin abuse indicators were stable or mixed in 15 CEWG areas, lower in 5, and

higher in 2 (Chicago and New Mexico). These indicators remained at high levels in Baltimore, Boston, Detroit, Los Angeles, New York City, Philadelphia, St. Louis, and San Francisco. Other data show that… • The proportions of heroin treatment admissions who injected the drug were especially high in Hawaii (90 percent), Los Angeles (87 percent), Denver (83), San Diego (82), and Maine (76 percent). • Increasingly, prescription opiate drugs are being used in combination with heroin in Hawaii, Maine, Miami, New York City, and Philadelphia.
Prescription opiate/narcotic analgesic drug abuse indicators continued to

be closely monitored by CEWG representatives. Selected findings show… • Across 13 CEWG areas reporting 2006 data on primary treatment admissions (excluding heroin and alcohol admissions) for other opiate abuse, increases occurred in Baltimore, Boston, Maine, and Seattle; decreases occurred in Denver and Detroit; and the proportions were relatively stable in Broward County, Florida, Cincinnati, New York City, St. Louis, and Texas. In Maine, other opiate drug treatment admissions constituted 42 percent of illicit drug treatment admissions in 2006. In the first half of 2006, the proportions of primary other opiate admissions, relative to total admissions, excluding alcohol, were also fairly high in Broward County (15.3 percent), Cincinnati (8.6 percent), Minneapolis/St. Paul (7.6 percent), Baltimore (7.4 percent), Texas (6.8 percent), Seattle (6.7 percent), and Boston (5.5 percent). In areas reporting 2005 treatment data, the proportions (excluding alcohol) of other opiate admissions were relatively low, ranging from 1.1 to 1.2 percent in Chicago and Los Angeles, respectively, to between 2.2 percent in San Diego and 3.2 and 3.6 percent, respectively, in Hawaii and Philadelphia. • Of the 13 CEWG areas participating in DAWN in the first half of 2006, the unweighted hospital ED opiate/opioid reports accounted for substantial proportions of the reports in the “other substances” category, which includes prescription-type drugs, over-the-counter drugs, and dietary supplements. As a proportion of the “other substances,” opiate/opioid reports were high in Minneapolis/St. Paul (32.6 percent), Ft. Lauderdale (34.6 percent), New York City (35.2 percent), and Seattle (36.2 percent), and they were lowest in MiamiDade County and Houston (21.2 and 22.9 percent, respectively). As a proportion of the total unweighted opiate/opioid ED reports, oxycodone reports were high in Boston (48.3 percent), Ft. Lauderdale (47.6), Miami (35.1), Minneapolis (38.6), Denver (31.2), and Phoenix (29.3 percent), while

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hydrocodone ED reports were high in Houston (47.5), San Diego (31.3), Detroit (27.0), and San Francisco (20.7). Areas with the highest proportions of methadone reports were New York City (56.1), Seattle (29.8), San Francisco (27.5), and Chicago (20.0). The proportions of fentanyl reports were relatively low compared with the proportions for other opiate/opioid drugs and were highest in Denver (6.7), Minneapolis (4.9), Detroit (4.5), Phoenix and San Diego (each 3.3 percent), and Boston (2.8). In the other seven CEWG areas, fentanyl reports accounted for between 0.4 percent (Houston) and 2.3 percent (Chicago and San Francisco) of the opiate/opioid reports. Across CEWG areas, substantial proportions of the reports (from 9 to 37 percent) were for unspecified opiates/opioids (see exhibit 9b). • Fentanyl-related deaths increased in Chicago (291 in 2006), Detroit (176 in the first 9 months of 2006), Philadelphia (103 in the first half of 2006), Florida (51 in the first half of 2006), Georgia (36 in FY 2006), Maryland (36 in 2006), and New York State (29 in January–November 2006). Fentanyl-related deaths remained stable in the St. Louis area, at 30 in 2006. Thirty fentanyl-related deaths were reported in Texas in 2005.
Marijuana abuse indicators remained stable at high levels in 15 CEWG areas,

increased in 5, and decreased in 2 (Maine and San Francisco). Marijuana continues to be the most widely available and widely used drug across CEWG areas, especially among adolescents and young adults. Considerations for the June 2007 CEWG Meeting Findings and issues identified by CEWG representatives in slide presentations, Abstracts, and telephone conference calls that should be considered in preparing for the June 2007 CEWG meeting included the following: • The types/forms/purity/place of origin of methamphetamine available in communities. It was reported that ice and/or crystal methamphetamine had become more available in many CEWG areas, but the drug’s type, form, and purity were not always distinguished. So, where possible, CEWG representatives should try to determine the types, forms, and purity of the methamphetamine available in communities. There were anecdotal reports in some CEWG areas that methamphetamine was being marketed in different colors and/or flavors. A 2006 HIDTA report indicated that “Strawberry” methamphetamine had been marketed in Carson City, Nevada.

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Key Findings and Considerations for the June 2007 CEWG Meeting

• The demographic characteristics of methamphetamine abusers (e.g., treatment admissions). If possible, comparisons should be made between methamphetamine abusers entering treatment for the first time and those who are reentering treatment. In addition, representatives should continue to… • Monitor opiate/opioid abuse indicators, especially for fentanyl, methadone, oxycodone, and hydrocodone abuse • Monitor cocaine/crack abuse indicators, especially in areas in which methamphetamine abuse indicators have decreased • Monitor heroin purity and price data, and the impact of changes on heroin abuse patterns and trends, including the combinations of drugs used

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COCAINE/CRACK
In 2005 and the first half of 2006, most cocaine/crack indicators were at higher levels than indicators for other drugs in 15 of the 22 CEWG areas. For example, in FY 2006, cocaine was the drug most frequently identified in items analyzed by forensic labs in 19 of 21 areas reported by NFLIS. In 10 CEWG areas, cocaine/crack treatment admissions (excluding alcohol) exceeded those for heroin and methamphetamine. Among treatment admissions in 2005 and/or 2006, the most common route of administration of cocaine was smoking. In 2006, the proportions of primary cocaine admissions who smoked the drug were highest in Detroit (94.5 percent), St. Louis (89.9 percent), Minneapolis/St. Paul (83.8 percent), Atlanta (78.5 percent), and Baltimore (77.4 percent); in 2005, between 83.0 and 86.0 percent of the primary cocaine admissions in Los Angeles and San Diego smoked the drug. In the 13 areas participating in DAWN, unweighted cocaine reports exceeded those for other major substances of abuse (excluding alcohol) in 12. In 16 CEWG areas, cocaine abuse indicators remained relatively stable at high levels.

the number of cocaine calls to the Helpline remained stable from 2005 to 2006. Though the number of cocaine drug arrests (Class B) and drug lab samples increased, the proportion of cocaine drug arrests and drug lab samples remained stable from 2004 to 2005. —Daniel Dooley
CHICAGO:

Epidemiological indicators continue to show that cocaine and marijuana are among the most commonly used illicit substances in Chicago. Cocaine was the second most frequently reported reason for entering treatment in FY 2005, and the trend was stable over the prior 5 years. Preliminary unweighted data from DAWN Live! show that cocaine accounted for the largest proportion of illicit drug reports in the first half of 2006, and cocaine was among the most frequently seized drugs by law enforcement in both FY 2005 and FY 2006, at 32 percent of all drug items. ––Lawrence Ouellet Drug abuse indicators continue to show cocaine/crack cocaine at high levels throughout Cincinnati. Twentysix percent of the known public treatment admissions for FY 2006 included primary cocaine use (including alcohol). Cocaine submissions recorded by NFLIS accounted for 48 percent of the total items reported and for 36 percent of the drug items recorded by the Hamilton County Coroner’s Office Laboratory. The average purity of cocaine items submitted to the Drug Enforcement Administration (DEA) Laboratory for analysis was 80 percent. Hamilton County law enforcement seizures of powder cocaine for the first 11 months of 2006 were twice those of the first 11 months of the previous year. Cocaine was detected in 49 decedents, second only to alcoholrelated deaths during the first 6 months of 2006. Intentional exposure cases where cocaine was recorded as an involved substance in poison control center data

ATLANTA:

Cocaine remains Atlanta’s primary drug concern, but patterns were relatively stable. Cocaine was the most mentioned drug among treatment admissions, drug abuse deaths, and NFLIS drug seizure data. —Brian Dew

CINCINNATI:

BALTIMORE: Treatment admissions for primary abuse of cocaine/crack increased slightly from around 16 percent in 2003– 2005 to 17 percent of admissions (excluding alcohol) in the first half of 2006. NFLIS items also increased slightly from 41 percent of drug items analyzed by forensic labs in FY 2005 to 43 percent in FY 2006. —Leigh Henderson BOSTON:

Cocaine abuse indicators for Boston are stable at high levels. Twenty-six percent of all treatment admissions indicated past-month cocaine use. The number of treatment admissions with pastmonth cocaine (including crack) use did not change from FY 2005 to FY 2006. Similarly,

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doubled from 2005 through 2006. —Jan Scaglione
DENVER: In the first half of 2006, primary cocaine treatment admissions, excluding alcohol, were relatively stable, at 23 percent of illicit drug admissions. Cocaine accounted for the highest illicit drug rate per 100,000 persons for hospital discharges from 1996 through 2005, for the highest number of illicit unweighted drug ED reports in the first half of 2006, and for 45 percent of the items reported by NFLIS in FY 2006, down from 49 percent in FY 2005. —Tamara Hoxworth DETROIT:

NEW YORK CITY:

Cocaine indicators continue to be stable, and cocaine remains a major problem in New York City. Excluding alcohol admissions, more than 56 percent of clients in treatment in the first half of 2006 reported cocaine as a primary, secondary, or tertiary drug. —Rozanne Marel

Cocaine continues to be a major drug of abuse in the area. Cocaine treatment admissions increased from FY 2005 to FY 2006, when this group accounted for 41 percent of the primary treatment admissions (excluding alcohol); 95 percent of the 2006 cocaine admissions were for crack abuse. Fifty-one percent of the unweighted ED illicit drug reports in the first half of 2006 were cocaine reports. In both FY 2005 and FY 2006, 46 percent of the drug items reported by NFLIS contained cocaine. In the first 9 months of 2006, deaths involving cocaine were higher than those for all other drugs. —Cynthia Arfken

PHILADELPHIA: Most cocaine indicators remained relatively stable. Cocaine abuse, particularly in the form of crack, continued to lead the consequence data in the first half of 2006 with respect to deaths with the presence of drugs, treatment admissions, and laboratory tests performed by NFLIS. It was the second substance most frequently encountered in urine/drug screens performed by the Philadelphia Adult Probation and Parole Department. —Samuel Cutler ST. LOUIS:

Crack cocaine continued to be the major problem in the area, but most indicators have remained relatively stable. Treatment admissions were down slightly (6 percent) from the first half of 2005 to the first half of 2006 in the St. Louis area, but they were up 9 percent statewide. —James Topolski

SAN FRANCISCO:

Cocaine was responsible for the highest number of drug consequences in Miami-Dade County, but indicators remained relatively stable. —James Hall
MIAMI/FT. LAUDERDALE:

Indicators for cocaine use showed a level trend in the 2003–2006 time period. ––John Newmeyer

Treatment admissions for primary abuse of cocaine/crack continued to account for between 26 and 27 percent of illicit drug admission (excluding alcohol) from 2003 to the first half of 2006. Cocaine also accounted for 26–27 percent of the items reported by NFLIS in FY 2005 and FY 2006. Nearly 38 percent of the unweighted illicit drug reports in DAWN Live! in the first half of 2006 were cocaine reports. ––Carol Falkowski
MINNEAPOLIS/ST. PAUL:

Both the rate and number of cocaine-involved deaths are at the highest levels seen in at least 10 years. According to unweighted data from area emergency departments, cocaine is the most commonly identified illicit drug. Treatment admissions for primary cocaine abuse remained relatively stable at around 24 percent of admissions (excluding alcohol). —Caleb Banta-Green
SEATTLE:

Cocaine is the primary illicit drug for which Texans enter treatment and it is a major problem on the border with Mexico, with increased purity levels and seizures. Indicators of cocaine use remain stable or are increasing. ––Jane Maxwell
TEXAS:

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EPIDEMIOLOGIC TRENDS IN DRUG ABUSE: HIGHLIGHTS AND EXECUTIVE SUMMARY

WASHINGTON, DC:

Cocaine remains one of the most serious drugs of abuse in the District, as evidenced by the fact that more adult arrestees tested positive for cocaine than for any other drug in 2006, and that number is increasing. In the first 9 months of 2006, approximately 40 percent of adult arrestees tested positive for cocaine at the Pretrial Services Agency. More seized items tested positive for cocaine than for any other drug, as reported by NFLIS in both FY 2005 and FY 2006 (44 vs. 41 percent). ––Erin Artigiani

slightly from 36 to 39 percent from FY 2005 to FY 2006. ––Beth Rutkowski Statewide, treatment admissions for cocaine/crack varied from 14 to 16 percent from FY 2003 to FY 2006. Cocaine accounted for approximately 30 percent of drug items analyzed by forensic labs in both FY 2005 and FY 2006. Hospital discharges for cocaine in Maricopa County increased slightly from the second half of 2005 to the second half of 2006. ––Ilene Dode
PHOENIX/ARIZONA: SAN DIEGO:

Increases in selected indicators were reported in three areas where cocaine abuse indicators are relatively low.

HONOLULU:

In the first half of 2006, there were 50 percent more decedents with positive cocaine toxicology screens, 50 percent more cocaine cases reported by the Honolulu Police Department, and 10 percent more cocaine admissions to treatment in the State. —D. William Wood

Treatment admissions remained relatively stable between 2004 and 2005, at around 8 percent of illicit drug admissions (excluding alcohol). Similarly, there was little change in the percentage of cocaine items reported by NFLIS in FY 2005 and FY 2006 (14–15 percent of all drug items). Cocaine accounted for 14 percent of the unweighted DAWN Live! ED reports in the first half of 2006. ––Robin Pollini

Fourteen percent of all 2006 treatment admissions involved a primary problem with cocaine; the proportion and number have risen steadily each year. Cocaine arrests by the Maine Drug Enforcement Agency rose 2 percent from 2004 to 2005, and 5 percent from 2005 to 2006. Deaths related to cocaine were level from 2004 to 2005, but projections suggest a 2006 decrease. ––Marcella Sorg
MAINE: NEW MEXICO:

PATTERNS AND TRENDS IN COCAINE ABUSE ACROSS CEWG AREAS Treatment Data on Cocaine/Crack
Exhibit 1a shows recent 2006 data on primary cocaine/crack treatment admissions from 16 CEWG areas; also presented in italic bold are data from 4 areas in which only 2005 data were available. In the 2006 time periods, primary cocaine/crack admissions as a proportion of all admissions, excluding alcohol, exceeded those for all other illicit drugs in Atlanta, Broward County, Cincinnati, Detroit, and St. Louis; in the four areas where 2005 data are shown, cocaine admissions exceeded those for other illicit drugs in Philadelphia.

Seizures of cocaine (in kilograms) increased 159 percent from 2003 to 2004, according to the El Paso Intelligence Center. ––Nina Shah

In three CEWG areas where cocaine/crack indicators are relatively low, patterns tended to remain relatively stable.

LOS ANGELES:

Treatment admissions for primary abuse of cocaine/crack (excluding alcohol) decreased slightly from 2003 to 2005 (23 vs. 21 percent), while cocaine items reported by forensic labs increased

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Exhibit 1a.

Primary Cocaine Treatment Admissions in 20 CEWG Areas, by Percent of All Admissions (Excluding Alcohol): 2003–20061 Year 2003 57.6 15.5 12.7 NR3 32.4 44.5 22.4 38.5 23.0 26.3 28.9 36.4 40.2 NR 25.9 22.6 16.2 6.3 10.9 38.2 2004 52.5 15.8 11.3 NR 32.7 41.7 23.2 35.6 22.0 26.1 29.5 33.8 40.9 8.7 29.7 21.8 16.1 6.3 11.4 35.7 2005 49.8 16.4 12.5 41.0 26.5 41.7 20.0 34.7 20.5 26.5 29.2 34.3 33.5 8.2 26.8 24.6 14.1 4.1 12.7 34.1 2006 50.6 17.3 12.0 37.9 NR 36.0 23.5 41.1 NR 27.0 29.4 NR 32.2 NR 29.4 24.0 14.6 6.4 14.2 33.2 Percent Smoked 2005––2006 78.5 77.4 60.0 NR 90.7 83.9 56.7 94.5 85.9 83.8 62.1 NR 89.9 82.8 81.7 NR NR NR 53.8 56.9

CEWG Area/State Atlanta Baltimore Boston Broward Co. (BARC)2 Chicago Cincinnati4 Denver Detroit Los Angeles Mpls./St. Paul New York Philadelphia5 St. Louis San Diego San Francisco Seattle Arizona Hawaii Maine Texas
1 2

Represents different time periods (FY 2005 or 2006, or 1H CY 2006, or full year CY 2005 or 2006); see Appendix A. The Broward County sample is from 9 programs that serve 51.5 percent of admissions to county treatment facilities. 3 NR=Not reported by the CEWG representative. 4 Represents 65–75 percent of the Cincinnati/Hamilton County admissions in the first half of 2006. 5 In the first half of 2006, cocaine/crack accounted for 33.5 percent of all drug mentions (excluding alcohol); data were not available for the “primary drug” category. SOURCES: June 2006 and January 2007 State and local reports

In January 2006, 12 areas reported on the route of cocaine administration. In all 12 areas, more than one-half of the primary cocaine admissions reported smoking cocaine.1 In Detroit in FY 2006, 94.5 percent of these admissions were for crack abuse. In St. Louis in the first half of 2006, nearly 90 percent of this admissions group smoked the drug. In Atlanta, Baltimore, Cincinnati, Minneapolis/St. Paul, and San Francisco, between 77 and 84 percent of the
1

primary cocaine admissions smoked the drug. In 2005, the proportions smoking cocaine were highest in Chicago, at nearly 91 percent. Gender. In 13 of 14 CEWG areas for which gender data were available, primary cocaine/crack treatment admissions were more likely to be male than female in both 2005 and 2006 (see exhibit 1b). The exceptions were Cincinnati and Texas, where just over one-half of the cocaine/crack admissions were female in the first half of 2006.

SAMHSA’s Treatment Episode Data Set report (2003) notes that “Smoked cocaine primarily represents crack or rock cocaine, but can also include cocaine hydrochloride (powder cocaine) when it is free-based.” TEDS uses smoked cocaine (crack).

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Exhibit 1b. Demographic Characteristics of Primary Cocaine Treatment Admissions in Reporting CEWG Areas, by Percent1: 2005–20062 Gender CEWG Area Atlanta Baltimore Chicago Cincinnati4 Denver Detroit Los Angeles Maine Mpls./St. Paul New York City Philadelphia St. Louis San Diego Seattle Texas
1 2

Race/Ethnicity Female 41 44 41 51 38 41 33 47 30 32 41 34 38 52 39 15 27 29 28 33 31 White 25 41 10 53 45 5 14 NR 52 58 63 70 58 51 36 5 24 11 1 11 5 32 Afr.-Amer. 73 56 82 45 21 93 57 Hispanic 1 2 6 NR 32 1 25

Male 59 56 59 49 62 59 67 53 70 68 NR 59 66 62 48

Age 35 or 36 or Older 82 71 NR3 NR 60 85 70 36 69 77 59 71 74 575 NR

Percentages rounded. Percentages shown in bold italic represent 2005 data. 3 NR=Not reported by the CEWG representative. 4 Represents 65–75 percent of the Cincinnati/Hamilton County admissions in the first half of 2006. 5 Represents admissions age 30–44 (another 25 percent were age 45–54). SOURCES: June 2006 and January 2007 State and local reports

Race/Ethnicity. In six of the nine CEWG areas reporting on race/ethnicity in 2006, more than one-half of the primary cocaine/crack admissions were AfricanAmerican, with the highest proportions being in Detroit (93 percent), Atlanta (73 percent), and St. Louis (70 percent); the lowest proportions were in Denver (21 percent), Texas (36 percent), and Cincinnati (45 percent) (see exhibit 1b). In Baltimore, Denver, and Cincinnati in 2006, Whites accounted for between 41 and 53 percent of these admissions groups, while in New York City, Denver, and Texas, between 24 and 32 percent of the cocaine/crack admissions were Hispanic. In 2005 in Chicago, 82 percent of the cocaine admissions were African-American.

Age. With the exception of Maine, a majority of the cocaine/crack admissions in 11 CEWG areas were age 35 or 36 or older in 2005 or 2006. In Maine in 2006, cocaine/crack admissions were nearly evenly divided between the 35 or older and 25–34 age groups, at 36 and 37 percent, respectively. Atlanta reported the highest proportion of cocaine/crack admissions age 35 and older (82 percent) in the first half of 2006. Trend Data. A comparison of 2003 to 2006 data from 15 CEWG areas shows that cocaine/crack admissions as a proportion of total admissions, excluding alcohol, decreased 7–8 percentage points in Atlanta, St. Louis, and Cincinnati (see exhibit 1a). Given the stable pattern in Cincinnati over

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the prior years, the pattern may continue to be stable when total figures are available for 2006. In Baltimore, Detroit, Maine, and San Francisco, there were small increases from 2003 to 2006 (from 1.8 to 3.5 percentage points). In the other nine CEWG areas, the trend was stable. In the four areas where only 2005 data are available, a 6 percentagepoint decrease occurred in Chicago from 2004 to 2005; the trend was relatively stable in the other four areas in 2005. In many CEWG areas, cocaine/crack was reported as a secondary or tertiary drug by treatment admissions, so it is often used in combination with other substances. The most recent data reported from eight areas show the following:
ATLANTA: Cocaine was the secondary drug of use among 30 percent of all treatment admissions in the first half of 2006. BALTIMORE: The

Cocaine was used as a primary, secondary, or tertiary drug by 39 percent of the admissions (excluding alcohol) in the first half of 2006.
BROWARD COUNTY:

Crack was reportedly the secondary drug of abuse among primary heroin admissions in FY 2006.
DETROIT:

Cocaine was the secondary drug of abuse among 30 percent of the primary heroin admissions, 29 percent of the primary alcohol admissions, and 13 percent of the primary marijuana admissions in the first half of 2006.
MINNEAPOLIS/ST. PAUL:

In the first half of 2006, 42 percent of all treatment admissions (including alcohol) reported any use of cocaine.
SEATTLE:

cocaine situation is complicated by the fact that for every drugrelated treatment admission (includes primary alcohol with secondary drug use) reporting primary cocaine use, 2.4 reported secondary use. Cocaine was the secondary drug of use among 35 percent of all admissions in the first half of 2006, and the secondary drug for 55 percent of the primary heroin admissions who abused another drug. Cocaine smoking and intranasal use were associated with intranasal heroin use in 34 percent of those who smoked cocaine or used it intranasally. Cocaine injection was associated with heroin injection in 89 percent of all admissions who injected cocaine.

In the first half of 2006, 22 percent of the primary heroin admissions had a problem with powder cocaine and 6 percent had a problem with crack cocaine. Of the primary marijuana admissions, 11 percent had a problem with powder cocaine and 2 percent had a problem with crack cocaine.
TEXAS:

DAWN ED Data on Cocaine/Crack
The map in exhibit 2 depicts the proportion of unweighted ED cocaine reports as a percentage of the total major substances of abuse (excluding alcohol) in the 13 CEWG areas participating in DAWN in the first half of 2006. Of all major substances (excluding alcohol), the unweighted cocaine reports accounted for the largest percentages of the reports in 12 of the 13 CEWG areas. The exception was San Diego, where methamphetamine ED reports exceeded those for other major substances.

BOSTON: Forty percent of all treatment admissions (including alcohol) in FY 2006 reported past-month use of cocaine.

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EPIDEMIOLOGIC TRENDS IN DRUG ABUSE: HIGHLIGHTS AND EXECUTIVE SUMMARY

Mortality Data on Cocaine/Crack
Eight CEWG representatives reported the most recent data on deaths with the presence of cocaine for their metropolitan or county areas. Detroit and Minneapolis/St. Paul reported for the first 9 months of 2006; the others reported for the first half of 2006. The numbers are as follows: 320 in Detroit/Wayne County 248 in Philadelphia 75 in Miami-Dade County 57 in Broward County, Florida 54 in Seattle/King County 49 in Cincinnati/Hamilton County 38 in Minneapolis/Hennepin County and St. Paul/Ramsey County 12 in Honolulu In addition, five CEWG representatives provided data on cocaine-related deaths specific to their States. In the first half of 2006, 927 cocaine-related deaths were reported in Florida. In FY 2006, 288 cocaine-involved deaths were reported in Georgia, and 432 were listed as positive for benzoylecgonine (a cocaine metabolite that is

excreted in the urine of cocaine users); these may represent some duplicate counts. In 2005, cocaine-involved deaths totaled 723 in Texas and 217 in Colorado. Maine reported 23 cocaine-induced deaths in 2005. Drug overdose deaths in Albuquerque/ Bernalillo County and the State of New Mexico in 2003–2005 were reported as rates per 100,000 population. The rate in the county in this time period was 7.72, higher than that for the State overall (5.49).

NFLIS Data on Cocaine/Crack
In FY 2006, cocaine was the drug most frequently reported by forensic laboratories in 15 of the 20 areas shown in exhibit 3, and it ranked second in 5 other areas. Cocaine accounted for more than one-half of all drug items analyzed by forensic labs in Miami, Ft. Lauderdale, Atlanta, and New York City in FY 2006, with Miami and Ft. Lauderdale substantially higher (71.3 and 68.8 percent, respectively) than other CEWG areas. The proportions of cocaine items to total items were considerably lower in San Diego and Honolulu than in other CEWG areas. Not shown in exhibit 3 is Albuquerque, where 37 percent of the items collected and analyzed by forensic labs in 2006 contained cocaine.

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EPIDEMIOLOGIC TRENDS IN DRUG ABUSE: HIGHLIGHTS AND EXECUTIVE SUMMARY

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Price Data on Cocaine/Crack
Exhibit 4a presents the cost per gram of powder cocaine in 21 CEWG areas, as reported by NDIC at mid-year 2006. As shown, the low end street price of a gram of cocaine was cheapest on the streets of New York City, Baltimore, and Phoenix, at $20 in both New York City and Baltimore, and $25 in Phoenix. The highest price for a gram of cocaine was $100 in Bangor, Maine, Cincinnati, and Minneapolis.
Exhibit 4a. Powder Cocaine Retail (Street) Price1 in 21 CEWG Areas2, Ordered by Lowest Price: June 2006 CEWG Area New York City Baltimore Phoenix Miami San Francisco Dallas Denver Seattle Detroit Albuquerque San Diego Honolulu Philadelphia Chicago Los Angeles Atlanta Boston Wash., DC Bangor, ME Cincinnati Minneapolis
1 2

Street prices for crack cocaine during the same time period are presented in exhibit 4b. In 19 areas, the prices were reported for a “rock,” and in 3 areas the prices were reported for a gram of crack. As can be seen, the street the price for a rock was lowest in New York City ($7). In 11 other areas, a rock could be purchased for $10. The street price for a gram was $100 in both Bangor and Washington, DC.
Exhibit 4b. Crack Retail (Street) Price in 22 CEWG Areas, Ordered by Lowest Price: June 2006 CEWG Area New York City Miami Boston Chicago Detroit Phoenix San Diego Seattle Baltimore Honolulu Los Angeles Dallas Minneapolis Albuquerque Atlanta Cincinnati Denver St. Louis San Francisco Price Per Rock $7–$10 $10 $10–$20 $10–$20 $10–$20 $10–$20 $10–$20 $10–$20 $10–$40 $10–$40 $10–$40 $10–$100 $15–$25 $20 $20 $20 $20 $20 $20 Price Per Gram $70 $100 $100
1

Price Per Gram $20–$30 $20–$200 $25–$30 $40–$100 $50–$60 $50–$80 $50–$80 $50–$100 $50–$120 $60–$120 $60–$160 $60–$200 $70–$125 $75–$100 $80 $80–$100 $80–$100 $80–$100 $100 $100 $100

Philadelphia Bangor, ME Wash., DC
1

Most current available price at mid-year 2006. Price per gram was not available for St. Louis. SOURCE: NDIC, DOJ

Most current available price at mid-year 2006. SOURCE: NDIC, DOJ

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EPIDEMIOLOGIC TRENDS IN DRUG ABUSE: HIGHLIGHTS AND EXECUTIVE SUMMARY

Heroin
Heroin abuse indicators increased in 2 CEWG areas, were mixed or stable at high levels in 5, were low and mixed or stable in 10, and decreased in 3 areas where abuse levels are relatively high and in 2 areas where indicators are at relatively low levels. Decreases in heroin purity levels are reportedly associated with changes in heroin use (mode of administration or use of other drugs) in some CEWG areas. Heroin abuse indicators increased in two CEWG areas.

race. In the first half of 2006, Baltimore continued to have a core of older AfricanAmerican heroin users, both intranasal users and injectors (39 and 21 percent of all heroin treatment admissions, respectively). White users entering treatment for heroin abuse were younger and were predominantly injectors rather than intranasal users (27 and 9 percent, respectively). —Leigh Henderson Heroin abuse remains stable at very high levels in Boston. In FY 2006, 76 percent of treatment admissions (excluding alcohol) identified heroin as their primary drug of abuse, and heroin admissions accounted for one-half of the total admissions (including alcohol). Though levels of heroin drug arrests (Class A) and drug lab samples decreased from 2004 to 2005, analysis of data for the first half of 2006 suggest that these levels may have stabilized. —Daniel Dooley
BOSTON: DETROIT:

Heroin use indicators have increased or remained at elevated levels since the mid-1990s. Drug treatment services for heroin use, which surpassed those for cocaine in FY 2001, have since nearly doubled to 33,662 episodes in FY 2005. According to preliminary unweighted DAWN Live! data, heroin was the second most commonly reported illicit substance in emergency departments during the first 6 months of 2006. —Lawrence Ouellet
CHICAGO: NEW MEXICO:

Heroin is the most significant drug threat in New Mexico in terms of abuse. In 2005, heroin caused the most unintentional overdose deaths…increasing roughly 40 percent from 2004. The rate of heroin overdose deaths from 2003 to 2005 was higher in Bernalillo County, where Albuquerque is located, than in the State overall. —Nina Shah

In FY 2006, heroin abuse indicators were mixed but remained at high levels. Heroin treatment admissions declined, but the number of heroin items reviewed by forensic laboratories increased. This followed an increase in heroin purity and a drop in price in 2005, as documented by the Domestic Monitor Program. The number of heroin items reviewed by forensic laboratories increased, possibly because of fentanyl surveillance. —Cynthia Arfken Heroin abuse indicators continued at relatively high levels, with increases in some indicators and decreases in others. The percentage of primary heroin treatment admissions (including alcohol) decreased from 23.9 percent in 2004 to 20.3 percent in 2005. In 2005, nearly 49 percent of the heroin treatment admissions were Hispanic. Heroin-related deaths appear to have increased by approximately 75 percent from 2002 to 2005, and this jump in deaths

Heroin abuse indicators remained stable or mixed at relatively high levels in five CEWG areas.

LOS ANGELES:

BALTIMORE:

Heroin remained the most significant substance of abuse among drugrelated treatment admissions in Baltimore in the first half of 2006, accounting for 55 percent of drug admissions (excluding alcohol). Heroin use in the area is complex. Several groups of heroin users differ by urbanicity, route of administration, age, and

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was most prevalent among users older than 40. —Beth Rutkowski
NEW YORK CITY:

Heroin indicators were mixed… In the first half of 2006, 38 percent of treatment admissions (excluding alcohol) were primary heroin abusers, down from 42 percent in 2003. Of the heroin admissions in the first half of 2006, 49 percent were Hispanic. There was concern that fewer heroin abusers were coming into methadone treatment. ––Rozanne Marel

Heroin abuse indicators continued to be low in Miami-Dade. Less than 3 percent of the items analyzed by Miami forensic labs in FY 2006 contained heroin; there were 22 heroin-related deaths in 2005 and 5 were reported in the first half of 2006. In the first half of 2006, heroin reports accounted for approximately 12 percent of the unweighted illicit drug DAWN ED reports in Miami-Dade County. ––James Hall
MIAMI:

Heroin abuse indicators were relatively low and mixed or stable in 10 CEWG areas.

CINCINNATI:

Heroin abuse continued to be relatively low. However, heroin treatment admissions (excluding alcohol) increased from 12 percent in FY 2003 to nearly 17 percent in FY 2006; also heroin accounted for 4 to 5 percent of law enforcement drug seizures in Cincinnati. ––Jan Scaglione Heroin abuse indicators remained relatively low and stable. Heroin accounted for less than 4 percent of illicit drug admissions and for less than 2 percent of the NFLIS items. Three deaths were positive for heroin, and there were six heroin arrest cases in the first half of 2006. ––D. William Wood

Heroin abuse indicators, while relatively low, remained stable at somewhat elevated levels. ––Carol Falkowski
MINNEAPOLIS/ST. PAUL:

HONOLULU:

In 2006, heroin abuse indicators remained relatively low. Statewide, primary heroin treatment admissions remained stable from FY 2003 to FY 2006, at about 11 percent of illicit drug admissions (excluding alcohol). Heroin accounted for 13.3 percent of the unweighted illicit drug ED reports, for approximately 12.0 percent of treatment admissions in the State, and for 5.5 percent of the items analyzed by NFLIS. —Ilene Dode
PHOENIX: SAN DIEGO:

Heroin indicators were mixed in Maine. The number of primary heroin admissions increased from 2005 to 2006, but the proportion decreased slightly—from 20 to 19 percent. Heroin/morphine-related deaths doubled from 2004 to 2005, but a review of these data indicate that many of the deaths involved pharmaceutical morphine. Heroin exposure calls to poison control centers were level from 2003 to 2005, but dropped in the first three quarters of 2006. Arrests for heroin possession or use made by the Maine Drug Enforcement Agency were stable from 2004 to 2005. —Marcella Sorg
MAINE:

Heroin ranked behind methamphetamine and marijuana in the number of ED reports in the unweighted DAWN data for the first half of 2006 and fourth in the number of NFLIS items reported in FY 2006. Heroin was the primary drug of abuse for nearly 24 percent of those admitted to treatment in 2005 (excluding alcohol), down slightly from 2004. Heroin was the primary drug of abuse for 72.4 percent of the primary injectors among treatment admissions in 2005. —Robin Pollini

The total of 30 heroin/opiateinvolved deaths is down somewhat compared with prior years. Treatment admissions for heroin remain relatively stable, with approximately 1 in 5 persons
SEATTLE:

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EPIDEMIOLOGIC TRENDS IN DRUG ABUSE: HIGHLIGHTS AND EXECUTIVE SUMMARY

reporting any heroin use at treatment entry for all ages and treatment modalities. In FY 2006, slightly more than 4 percent of the items analyzed by forensic labs (NFLIS) contained heroin. —Caleb Banta-Green Heroin indicators in Texas areas were stable or dropping; most heroin addicts entering treatment were injectors. Heroin purity is increasing, and ‘cheese,’ a mixture of Tylenol PM and 1 percent heroin, has been reported in Dallas schools. —Jane Maxwell
TEXAS: WASHINGTON, DC:

Most heroin abuse indicators decreased over the past several years, although poison control calls remained stable. In the first half of 2006, heroin was reported as a primary drug for about 9 percent of Denver treatment admissions (excluding alcohol), down from 22 percent in 2003. ––Tamara Hoxworth
DENVER: PHILADELPHIA: Indicators remained mostly stable at high levels. The decline in streetlevel purity of heroin since 2000 (73 percent) appears to have caused users to seek or approximate a high through the use of increased amounts or adding other drugs to use in combination. —Samuel Cutler ST. LOUIS:

Reports from the Pretrial Services Agency indicate that the percentage of adult arrestees testing positive for opiates remained about the same from 2001 through the first 3 months of 2006. From January through March 2006, almost 9 percent of the adult arrestees tested positive for opiates. NFLIS data for 2005 show that about 11 percent of the items analyzed by forensic labs in the District tested positive for heroin. —Erin Artigiani

Heroin activity had been increasing, but treatment admissions in the St. Louis area decreased 11 percent from the first half of 2005 to the first half of 2006 and decreased statewide over the same period by 5 percent. —James Topolski

Heroin abuse indicators decreased in five CEWG areas, remaining relatively high in Philadelphia, St. Louis, and San Francisco and relatively low in Atlanta and Denver.

ATLANTA: Heroin abuse indicators continued to decrease in 2006, with the majority of abusers concentrated in Atlanta’s Bluff district. Rates of injecting South American (SA) heroin remained stable, although reports indicated a decrease in purity levels and an increase in price. The types (origin) of heroin exhibits purchased by DMP in 2005 varied: 13 were from South America, 5 from Southwest Asia, and 4 from Southeast Asia. The average street price for SA heroin in Atlanta was $2.04 per milligram pure, the most expensive average price for heroin (of any type) in all DMP areas reported by the program in 2005. ––Brian Dew

Heroin abuse indicators, while continuing at high levels, have been consistently declining since 2000, although FY 2005 treatment data suggest the trend may be reversing. The 27 DMP exhibits purchased in 2005, all from Mexico, averaged 12.3 percent in purity. —John Newmeyer
SAN FRANCISCO:
Heroin purity remained low in most CEWG areas east of the Mississippi River—areas in which South American (SA) heroin dominated the heroin markets in 2005. The average purity of SA heroin was lower than 50 percent per milligram pure in all CEWG areas east of the Mississippi, including Chicago (17.1 percent), Miami (19.4), Washington, DC (20.2), Baltimore (29.1), Boston (29.4), Atlanta (39.3), and Detroit (46.6). An exception may be St. Louis, where South American heroin is becoming more available, as indicated below.

Decreases in heroin purity were reported in two eastern CEWG areas that have been identified as significant heroin markets and distribution centers by the DEA, while

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increases in heroin purity are being reported in St. Louis.
NEW YORK CITY: The heroin purity level

areas, including Seattle (10.4 percent), San Francisco (11.1 percent), St. Louis (14.4 percent), Dallas (16.3 percent), Los Angeles (31.4 percent), and Denver (34.4 percent).
CEWG representatives monitor the purity of drugs by area because of the potential impact purity levels can have on the way heroin is administered, the extent to which other drugs are used sequentially or in combination with heroin, and the types of other substances used with heroin. For example…

was at 49.4 percent in 2005, up from the last reporting period, but still lower than the 60.0 percent reported in recent years. However, there is some evidence that purity levels are increasing, back to the 50.0 percent range. —Rozanne Marel The street-level of heroin purity declined from 73 percent pure in 2000 to 38 percent in the first quarter of 2006. —Samuel Cutler
PHILADELPHIA: ST. LOUIS:

MIAMI: Less pure heroin may explain the substantial increases in the abuse and consequences of narcotic analgesics in recent years. —James Hall

In St. Louis, the heroin problem is becoming more complex. In past years, most heroin available on the street was low purity black tar heroin. In the past year, DMP reported seizures of South American heroin that were almost 30 percent pure; it sold for $1 per milligram pure––$0.50 less per milligram than a couple of years ago. DEA also seized Southwest Asian samples in 2005; they cost less than $2 per milligram and were nearly 30 percent pure. Historically, these are the cheapest and purest heroin samples identified in St. Louis. ––James Topolski

The Street Studies Unit of the New York State Office of Alcoholism and Substance Abuse Services is currently assessing the extent to which heroin abusers are stabilizing heroin with multiple pharmaceuticals. —Rozanne Marel
NEW YORK CITY:

Mexican black tar and brown-powder heroin dominate the market west of the Mississippi (DMP 2005).

Clients who are new to treatment identify six behavior changes associated with low heroin purity: switching to injecting from other routes of administration; injecting more heroin; injecting more frequently; using additional drugs; switching to pharmaceutical drugs that have more reliable purity and predictable effects; and entering treatment. ––Samuel Cutler
PHILADELPHIA:

Most 2005 DMP heroin exhibits purchased on the street in the western region originated in Mexico. Of these CEWG areas, heroin purity levels (per milligram pure) were highest in areas on or close to the U.S.Mexico border, including San Diego (averaging 55.9 percent) and Phoenix (53.1 percent). The heroin purchases in these two areas were exclusively black tar heroin selling at low prices on the street, e.g., $0.20 per milligram pure in San Diego and $0.49 in Phoenix. The DMP 2005 average purity levels were lower in other western region

PATTERNS AND TRENDS IN HEROIN ABUSE ACROSS CEWG AREAS Treatment Data on Heroin
Primary heroin admissions as a proportion of all admissions, excluding alcohol, exceeded those for all other illicit drug admissions in four CEWG areas reporting 2006 data:

Proceedings of the Community Epidemiology Work Group, January 2007

25

EPIDEMIOLOGIC TRENDS IN DRUG ABUSE: HIGHLIGHTS AND EXECUTIVE SUMMARY

Baltimore, Boston, New York City, and San Francisco. In 2005 (shown in italic bold), heroin admissions exceeded those for other

illicit drugs in Chicago. Data for 2003–2006 are depicted in exhibit 5a.

Exhibit 5a. Primary Heroin Treatment Admissions in 20 CEWG Areas, by Percentage of All Admissions (Excluding Alcohol): 2003–20061 CEWG Area/State Atlanta Baltimore Boston Broward Co. (BARC)2 Chicago Cincinnati4 Denver Detroit Los Angeles Mpls./St. Paul New York Philadelphia5 St. Louis San Diego San Francisco Seattle Arizona Hawaii Maine7 Texas
1 2

2003 8.5 61.7 73.4 NR3 48.1 12.2 22.5 43.1 31.1 6.7 42.3 31.4 11.7 NR 35.6 25.1 11.7 3.6 20.7 13.6

2004 7.6 60.7 74.2 NR 47.3 13.2 13.6 46.0 30.1 5.6 42.1 36.0 18.4 25.0 42.8 27.0 19.6 3.0 21.3 13.7

2005 7.0 59.5 75.6 21.8 53.0 10.8 14.1 43.6 24.4 9.8 40.8 22.7 16.0 23.8 41.0 25.4 10.6 3.1 20.5 11.6

2006 7.2 55.2 75.9 18.0 NR 17.2 9.2 38.1 NR 10.9 38.4 NR 16.1 NR 42.06 21.8 11.0 3.6 18.7 11.8

PercentagePoint Change 2003–2006 -1.3 -6.5 2.5 … … 5.0 -13.3 -5.0 … 4.2 -3.9 … 4.4 … …6 -3.3 -0.7 0.0 -2.0 -1.8

Represents different time periods (FY 2005 or 2006, or 1H CY 2006, or full year CY 2005 or 2006); see Appendix A. The Broward County sample is from 9 programs that serve 51.5 percent of admissions to county treatment facilities. 3 NR=Not reported by the CEWG representative. 4 Represents 65–75 percent of the Cincinnati/Hamilton County admissions in the first half of 2006. 5 In the first half of 2006, heroin accounted for 23.5 percent of all drug mentions (excluding alcohol); data were not available for the “primary drug” category. 6 Includes a small but unknown number of admissions for other opiates; therefore, the percent change from 2003 to 2006 could not be determined. 7 Includes morphine as well as heroin. SOURCES: June 2006 and January 2007 CEWG reports

Gender. In 16 reporting CEWG areas, there were more males than females among primary heroin admissions groups in the 2005–2006 reporting periods (see exhibit 5b). Note, however, that nearly one-half of this group in Chicago and Maine were female. Race/Ethnicity. In the nine CEWG areas reporting 2006 data, African-Americans were the most frequently represented racial/ethnic group among heroin admissions in Baltimore,

Detroit, and St. Louis; Whites were more frequently represented in Atlanta, Cincinnati, Denver, and Minneapolis/St. Paul; and Hispanics were most frequently represented in New York City and Texas (see exhibit 5b). In 2005, African-Americans accounted for the largest proportion of primary heroin admissions in Chicago, and Whites were the most dominant group in Hawaii, Philadelphia, San Diego, and Seattle. Hispanics accounted for 49 percent of primary heroin admissions in Los Angeles in

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Proceedings of the Community Epidemiology Work Group, January 2007

Drug Abuse Patterns and Trends Across CEWG Areas: Heroin

2005 and for 40 percent of the heroin admissions in San Diego in that year. Age. In nine CEWG areas in the 2005–2006 reporting periods, between 55 and 88 percent of the primary heroin admissions

were older than 35 or 36 (or 30–44 in Seattle), indicating an aging cohort (see exhibit 5b). In Maine and St. Louis in the first half of 2006, the largest proportions of primary heroin admissions were younger than 35.

Exhibit 5b. Demographic Characteristics of Primary Heroin Treatment Admissions in Reporting CEWG Areas, by Percent1: 2005–2006 CEWG Area Atlanta Baltimore Chicago Cincinnati Denver Detroit Hawaii Los Angeles Maine Mpls./St. Paul New York Philadelphia St. Louis San Diego Seattle Texas
1 2

Male 69 58 51 56 68 59 72 74 52 69 75 77 63 72 62 64

Gender Female 31 42 49 44 32 41 28 26 48 31 25 23 37 28 38 36

White 49 37 8 85 63 7 66 36 61 20 51 46 50 67 33

Race/Ethnicity Afr.-Amer. Hispanic 47 4 61 2 82 8 <15 NR 8 25 90 1 <1 8 10 49 NR 33 3 26 49 21 13 53 2 6 41 16 7 11 56

Age 35 or 36 or Older 81 68 NR2 NR 59 85 NR 75 (18)3 55 77 NR4 (32)5 58 80 NR

Percentages rounded. NR=Not reported by the CEWG representative. 3 Heroin/morphine admissions were evenly divided at 41 percent each for clients under age 25 and those 25–34. 4 Heroin admissions younger than 26 accounted for 26 percent and those 26–35 accounted for 36 percent. 5 St. Louis heroin admissions are somewhat evenly divided with 38 percent being age 26–34 and 29 percent being younger than 26. SOURCES: June 2006 and January 2007 CEWG reports

Route of Administration. Exhibit 5c depicts the major routes of heroin administration in 12 CEWG areas, showing that injection was the most common mode in 9 of the 12 areas in 2005 or 2006. In 2006, injection was the most frequently reported mode of heroin administration in Atlanta, Denver, Maine, Minneapolis/St. Paul, and St. Louis (ranging from 52 to 83 percent) and was slightly dominant in Baltimore at 49 percent. Including both 2005 and 2006 data, the highest percentages of heroin injection tended to be in West Coast areas, where black tar heroin is the most available form of

the drug; figures ranged from 82 percent of the heroin admissions in San Diego to 90 percent in Hawaii. In the other five CEWG areas, sniffing/intranasal use was the predominant mode of heroin administration; this tended to be more common in areas where South American heroin is the dominant form of the drug or at least is available in the area. Sniffing/intranasal use was almost as dominant as injection among heroin admissions in Baltimore and ranged between 53 and 82 percent in Detroit, New York City, and Chicago.

Proceedings of the Community Epidemiology Work Group, January 2007

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EPIDEMIOLOGIC TRENDS IN DRUG ABUSE: HIGHLIGHTS AND EXECUTIVE SUMMARY

Exhibit 5c. Major Routes of Administration of Heroin Among Treatment Admissions in 12 CEWG Areas, by Percent1: 2005–20062
27 5 49 48 65

Atlanta

3

Baltimore

2 1 15

Chicago Chicago

2 1 7 9 46

82

83

Denver 1

Detroit

<1 <1 <1 2 4 2

53

90 7 87 7 76 Injection 35 61 Sniffing/Intranasal Smoking Other/Multiple/Unknow n 38 61

Hawaii Haw aii

Los Angeles Los Angeles

Maine

1

18 4

Mpls./St. Paul 0

4

New York

<1 <1 43 4 4 0.3 52

St. Louis

1

82 12

San Diego San Diego

1

2

Percentages rounded. Represents different time periods (FY 2005 or 2006, or 1H CY 2006, or full year CY 2005 or 2006); see Appendix A. SOURCES: June 2006 and January 2007 CEWG reports

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Proceedings of the Community Epidemiology Work Group, January 2007

Drug Abuse Patterns and Trends Across CEWG Areas: Heroin

In Texas, 84 percent of the treatment admissions in the first half of 2006 injected heroin. Trends. Across CEWG areas reporting 2006 data, primary heroin admissions, as a proportion relative to all treatment admissions, excluding alcohol, increased 4– 6 percentage points in Minneapolis/St. Paul, St. Louis, Cincinnati, and San Francisco, when 2003 data are compared with those for 2006 (see exhibit 5a). Conversely, primary heroin admissions decreased approximately 7 and 13 percentage points in Baltimore and Denver, respectively, over the same time period.

Detroit/Wayne County, 185 Philadelphia, 165 (including morphine) Seattle/King County, 38 (that approximate heroin) Broward County, 9 Miami/Dade County, 5 Cincinnati, 5 Honolulu, 3 Statewide in 2005, there were 446 deaths with the presence of heroin/morphine in Texas and 42 heroin-involved deaths reported in Colorado; Maine reported 44 heroin/morphine-induced deaths. In Florida in the first half of 2006, there were 36 heroin-related deaths. The rate of heroin overdose deaths in Albuquerque/Bernalillo County in 2003– 2005 was 8.58 per 100,000 population, higher than the rate of 5.72 for the State of New Mexico overall.

DAWN ED Data on Heroin
Unweighted DAWN Live! data for the first half of 2006 show that heroin was the second most frequently cited major substance of abuse (excluding alcohol) among ED reports in Boston, Chicago, Detroit, New York City, San Francisco, and Seattle (see the map in exhibit 2). In Boston and Chicago, the unweighted heroin reports accounted for 35–36 percent of the major substance of abuse reports (excluding alcohol), and in Detroit and New York City, heroin accounted for 25 and 27 percent of the reports, respectively. The approximate proportions were lower in San Francisco (16 percent) and Seattle (21 percent).

NFLIS Data on Heroin
In CEWG areas in FY 2006, heroin was the third most frequently reported drug by NFLIS labs in 10 of the 21 areas depicted earlier in exhibit 3. Heroin as a percentage of total drug items was relatively high in Baltimore (22.7 percent) and Detroit (20.7); it ranged between 11.4 and 15.0 percent of the drug items in New York City, St. Louis, Boston, and Chicago; and heroin represented 8.2 and 9.6 percent of the items in Washington, DC, and Philadelphia, respectively.

Mortality Data on Heroin
The most recent data on deaths with the presence of heroin are summarized below. The data for Detroit/Wayne County are for the first 9 months of 2006; heroin-related mortality data for the other metropolitan/ county areas are for the first half of 2006.

Heroin Price Data
NDIC Data on Price

Exhibit 6 presents the cost per gram of white powder heroin in 10 CEWG areas and for

Proceedings of the Community Epidemiology Work Group, January 2007

29

EPIDEMIOLOGIC TRENDS IN DRUG ABUSE: HIGHLIGHTS AND EXECUTIVE SUMMARY

black tar heroin in 8 CEWG areas, as reported by the NDIC at mid-year 2006. As shown, the low end range for white powder heroin street prices per gram was cheapest in
Exhibit 6.

New York City and Boston, while black tar heroin was cheapest in San Francisco, Seattle, and Los Angeles.

Retail (Street) Price1 per Gram of White Powder and Mexican Black Tar Heroin in 18 CEWG Areas, Ordered by Lowest Price: June 2006 Mexican Black Tar Heroin CEWG Area Price Per Gram San Francisco $40 Seattle $40–$80 Los Angeles $40–$100 San Diego $50–$100 Phoenix $60–$80 Dallas $150–$250 Honolulu $150–$300 Denver $200

White Powder Heroin CEWG Area Price Per Gram New York City $45–$100 Boston $53–$100 Baltimore $65–$165 Philadelphia $65–$300 Chicago $70–$200 Miami $100–$150 Washington, DC $100–$150 Atlanta $100–$400 Bangor, ME $300 Minneapolis $300–$400
1

Most current available price at mid-year 2006. SOURCE: NDIC, DOJ

In Cincinnati, a bag of heroin cost $20. In Detroit, a bag of white heroin sold for $10– $20. In St. Louis, a “button” of heroin cost $10.

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Proceedings of the Community Epidemiology Work Group, January 2007

Drug Abuse Patterns and Trends Across CEWG Areas: Other Opiates/Narcotic Analgesics

Other Opiates/Narcotic Analgesics
The abuse of a variety of prescription-type opiates/narcotic analgesic drugs was reported across CEWG areas. The particular types of opiate/narcotic analgesics, populations using these drugs, the reasons for using these drugs, and the consequences of use, differed across and within CEWG areas. An update of the fentanyl data reported at the June 2006 CEWG meeting shows that substantial numbers of fentanylrelated deaths continued to be reported in six CEWG areas, with increases reported in five. Methadone abuse indicators, reported from 15 CEWG areas, signal the serious consequences of the drug, especially the mortality data from 9 areas. In 17 reporting areas, abuse indicators were typically highest for oxycodone and hydrocodone. Oxycodone abuse indicators were higher than hydrocodone indicators in eight areas, while hydrocodone indicators were higher in seven. Indicators of abuse of codeine continued to be high in Detroit and Philadelphia. Excerpts from the January CEWG data and telephone conference calls are presented below; more quantitative data appears in the following section.

Exhibit 7. Fentanyl ED Reports in 13 CEWG Areas (Unweighted1): January–June 2006 Fentanyl Reports2 38 23 29 60 19 3 5 46 11 28 15 8 30 Fentanyl Reports as a Percentage of Other Opiates/ Opioids Reports 2.8 2.3 6.7 4.5 2.1 0.4 1.8 4.9 0.6 3.3 3.3 2.3 2.0

CEWG Area Boston Chicago Denver Detroit Ft. Lauderdale Houston Miami-Dade Mpls./St. Paul New York City Phoenix San Diego San Francisco Seattle
1

All DAWN cases are reviewed for quality control, and based on review, may be corrected or deleted. Therefore, these data are subject to change. 2 Reports include those for “seeking detox,” “overmedication,” and “other.” SOURCE: DAWN Live!, OAS, SAMHSA, updated 11/17– 11/20, 2006

Fentanyl
Fentanyl and fentanyl mixture abuse indicators continued to increase in Chicago, Detroit, Georgia, Maryland, and Philadelphia. The following data provide an update to the information from the June 2006 CEWG meeting.

Recent data from six CEWG areas where fentanyl abuse signaled an “alarm” for the June 2006 meeting are presented below. Most of the data refer to deaths related to fentanyl; these may be underreported because medical examiners do not consistently test for the presence of fentanyl.

As in 2005, the 2006 CEWG treatment data did not specifically differentiate fentanyl from “other opiates.” The FY 2006 NFLIS data show 216 fentanyl items reported in 8 CEWG areas, where they accounted for less than 1 percent of all drug items; 63 percent of the 216 items were reported from Philadelphia (n=137) and St. Louis (56). In the other six areas, the numbers of fentanyl items were small: Boston (1), Chicago (2), Baltimore (4), Minneapolis/St. Paul and San Diego (each 5), and San Francisco (6). As in 2005, there were a few reports of fentanyl in the first half of 2006 in the DAWN Live! data, as shown in exhibit 7; their proportion in comparison to other opiate/opioid ED reports is depicted later in exhibit 9.

There were 291 deaths involving fentanyl and fentanyl mixtures in 2006 (another 22 were reported in the last half of 2005). Of the 313 deaths from May 1, 2005, to November 11, 2006, 85 percent were male, 60 percent were African-American, and 40 percent were White; the median age was 41; and 20 percent died outside the city of Chicago. Data from the Chicago Forensic Science Center, Illinois State Police, show dramatic increases in the number of items from metropolitan Chicago containing fentanyl: 1 in 2003, 3 in 2004, 22 in 2005, and 1,330 in 2006. ––Lawrence Ouellet
CHICAGO:

Proceedings of the Community Epidemiology Work Group, January 2007

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EPIDEMIOLOGIC TRENDS IN DRUG ABUSE: HIGHLIGHTS AND EXECUTIVE SUMMARY

DETROIT:

Deaths involving fentanyl increased more than 272 percent from 2005, with 176 reported between January and September 2006. Trend data show 3 such deaths in 2000, 7 in 2001, 12 in 2002, 20 in 2003, 29 in 2004, and 63 in 2005. A local work group has been created in response to the growing fentanyl problem, and a formal investigation is underway by the Centers for Disease Control and Prevention. ––Cynthia Arfken

of St. Louis. The problem appears to be relatively contained. It is likely that only one source from Chicago was involved, and things got ‘quiet’ after the bust of the fentanyl-dealing gang in Chicago. Little has appeared in the media since the summer of 2006. ––James Topolski
Data from six other CEWG areas provide some information from one particular fentanyl abuse indicator.

Deaths involving fentanyl totaled 36 in FY 2006, compared with 12 in FY 2005. ––Brian Dew
GEORGIA:

CINCINNATI:

There were 28 calls involving fentanyl to the Cincinnati Poison Control Center in 2006. ––Jan Scaglione

There have been 2 spikes in fentanyl-related deaths in Maryland––1 in 2003 and the other in 2006, when 36 fentanyl deaths were reported. About onehalf of last year’s fentanyl-related deaths also tested positive for heroin, and about one-half tested positive for cocaine. –– Erin Artigiani
MARYLAND: PHILADELPHIA:

Statewide in the first half of 2006, 51 deaths involving fentanyl were reported. Fentanyl was lethal in 60 percent of these deaths. ––James Hall
FLORIDA: LOS ANGELES:

By June 2006, there were 103 deaths with the presence of fentanyl; of the 556 drug mortality cases in the first half of 2006, fentanyl was detected in 19 percent. Most of the deaths were classified as Adverse Reactions, and some were called Overdoses. Trend data show between 4 and 5 per year from 2000 to 2002, 16 in 2003, and 36 in both 2004 and 2005. Of 43 deaths with the presence of fentanyl from April 17 to May 31, 2006, an average of 6.25 drugs were detected in the fentanyl-positive cases. Of the 103 deaths with fentanyl reported by June 30, some included fentanyl in combination with cocaine but not heroin; 69 were a combination of heroin and fentanyl. The first mortality cases in which fentanyl was added to packets containing and sold as heroin were recorded on April 17, 2006. ––Samuel Cutler In 2006, 30 deaths involving fentanyl were reported; 14 were in the city

From 2000 through 2005, sales of fentanyl base to pharmacies and hospitals in Los Angeles County increased 122 percent. In 2005, 20,224 grams of fentanyl base were sold, accounting for 0.3 percent of the sales of opiate-type drugs to pharmacies and hospitals in the county. ––Beth Rutkowski

MINNEAPOLIS/ST. PAUL:

Seven deaths involving fentanyl were reported from Hennepin and Ramsey Counties from January through September, 2006. ––Carol Falkowski From January through November 2006, there were 29 deaths involving fentanyl; 5 were in Harlem. Ethnographic interviews with active users in Harlem in the summer and fall of 2006 indicated there was no increase in nonfatal overdoses or strange reactions to heroin, no changes in marketing, no new sellers, and a general unawareness among users of fentanyl to the dangers associated with the drug. ––Rozanne Marel

NEW YORK CITY:

ST. LOUIS:

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Proceedings of the Community Epidemiology Work Group, January 2007

Drug Abuse Patterns and Trends Across CEWG Areas: Other Opiates/Narcotic Analgesics

In 2005, there were 30 death certificates with a mention of fentanyl in Texas. ––Jane Maxwell
TEXAS:

items reported by NFLIS in FY 2006. ––Lawrence Ouellet There were 41 methadone Intentional Exposure Cases reported by the poison control center in 2006, making it the third most frequently reported opiate drug. Methadone accounted for 0.4 percent (n=68) of the drug items reported by NFLIS. ––Jan Scaglione
CINCINNATI: DETROIT:

Methadone
Methadone abuse indicator data were reported from 15 CEWG areas. Nine areas reported on deaths involving methadone, indicating the most serious problem related to abuse of this drug.

In FY 2006, there were 153 deaths involving methadone; these accounted for 7.7 percent of positive drugtype specimens. In the Atlanta metropolitan area in FY 2006, there were 93 methadone items reported by NFLIS, accounting for 0.55 percent of all drug items. ––Brian Dew
ATLANTA/GEORGIA: ALBUQUERQUE/NEW MEXICO: The ageadjusted rate of methadone deaths per 100,000 population in 2003–2005 was higher in Albuquerque/Bernalillo County than in the State overall (3.13 vs. 2.00), and methadone continues to be the opiate most likely to cause overdose death. —Nina Shah

In the first 9 months of 2006, there were 77 deaths involving methadone in Wayne County, compared with 86 in all of 2005. Methadone accounted for nearly 12 percent of the unweighted opiate/opioid ED reports in the first half of 2006. ––Cynthia Arfken There were 10 deaths involving methadone in the first half of 2006. ––D. William Wood Sales of methadone to hospitals and pharmacies in Los Angeles County increased 117 percent between 2001 and 2005. ––Beth Rutkowski

HONOLULU:

LOS ANGELES:

Of the 9,626 drug-related calls to the poison control center in 2005, 31 involved methadone. In FY 2006, there were 117 methadone items identified by forensic labs, accounting for 0.3 percent of all drug items. ––Leigh Henderson
BALTIMORE: BOSTON:

Methadone has caused more deaths than any other drug (38 percent of the drugs deaths in 2005), with the majority involving tablets; the rate appears to have stabilized. Some methadone treatment clients are now using cocaine for a ‘high.’ Methadone prescribed by physicians appears to be one ‘gateway’ to heroin use. ––Marcella Sorg
MAINE: MIAMI/FT. LAUDERDALE/FLORIDA:

Methadone represented nearly 17 percent of the unweighted opiate/opioid ED reports in the first half of 2006 and 0.3 percent (n=23) of the total drug items reported by NFLIS. ––Daniel Dooley

In the first half of 2006, methadone accounted for one-fifth of the unweighted opiate/opioid ED reports in the metropolitan area. Methadone was contained in 82 (0.1 percent) of the drug
CHICAGO:

Methadone leads all other opiates in drugrelated deaths locally and statewide. In Broward County, 45 percent of the 29 deaths involving methadone were lethal (i.e., the cause of death). Methadone was lethal in all three methadone deaths reported in Miami-Dade County.—James Hall
NEW YORK CITY: Methadone

ED reports represented 56 percent of the unweighted

Proceedings of the Community Epidemiology Work Group, January 2007

33

EPIDEMIOLOGIC TRENDS IN DRUG ABUSE: HIGHLIGHTS AND EXECUTIVE SUMMARY

opiate/opioid ED reports in the first half of 2006. Many kinds of prescription drugs are increasingly popular and available on the street. —Rozanne Marel
PHILADELPHIA: Deaths with the presence of methadone increased from 10 in 1998 to 132 in 2004, decreased to 113 in 2005, and are projected to reach 138 in 2006. ––Samuel Cutler

Helpline calls for opiates decreased slightly in 2006. The number of oxycodone drug lab samples increased from 2004 to 2005; however, the estimate for 2006, based on data for the first half of the year, was similar to 2004 and previous years. —Daniel Dooley
BOSTON: DETROIT: Deaths

Deaths with a mention of methadone increased from 30 in 1998 to 164 in 2004 to 205 in 2005. Calls to the poison control center increased from 16 in 1998 to 106 in 2004 but decreased to 71 in 2005. Treatment admissions for a primary problem with non-prescription methadone increased from 55 in 1998 to 91 in 2005 and totaled 43 in the first half of 2006. Forensic lab items containing methadone increased from 1 in 1998 to 133 in 2005 and totaled 101 in 2006. Methadone users are predominately White, and the more adverse events appear to be related to methadone pain pills. —Jane Maxwell
TEXAS:

related to codeine, fentanyl, hydrocodone, methadone, and oxycodone increased in Wayne County from 2005 to the first 9 months of 2006. ––Cynthia Arfken

Hydrocodone, Oxycodone, and Codeine
Hydrocodone and oxycodone continue to be the most widely abused other opiates in many CEWG areas; misuse of codeine is also reported. Examples are presented below.

In 2005, poison control calls involving exposure to methadone constituted the largest proportion of all narcoticsrelated calls, but was followed closely by hydrocodone (20 percent) and oxycodone (19 percent). Oxycodone primary admissions dominate the2006 narcotic analgesic distribution at 31 percent of drug treatment admissions (excluding alcohol); 41 percent of heroin admissions report oxycodone as a secondary or tertiary problem. Maine’s prescription monitoring program reports that hydrocodone/ acetaminophen is the most common controlled substance prescription (21 percent), followed by oxycodone preparations (11 percent) and lorazepam (8 percent). The Maine Drug Enforcement Administration arrests involving prescripttion drugs increased from 22 to 25 percent from 2004 to 2006. —Marcella Sorg
MAINE:

Excluding alcohol, narcotic analgesics accounted for nearly one-half of the drug-related deaths statewide in the last half of 2006. Deaths with the presence of codeine, hydrocodone, methadone, and morphine increased statewide from 2005 to FY 2006. Multiple abuse indicators show that hydrocodone is the most commonly abused narcotic analgesic in Atlanta, followed by oxycodone. ––Brian Dew
ATLANTA/GEORGIA:

Deaths with a presence of most narcotic analgesics increased over the past several years, including deaths involving codeine, methadone, and oxycodone. Deaths with the presence of codeine increased steadily from 3 in 1998 to 139 in 2005, and they are projected to reach 198 in 2006. Deaths with the presence of oxycodone increased from 1 in 1996 to 119 in 2005, and are projected to total 136 in 2006. —Samuel Cutler
PHILADELPHIA:

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Proceedings of the Community Epidemiology Work Group, January 2007

Drug Abuse Patterns and Trends Across CEWG Areas: Other Opiates/Narcotic Analgesics

Codeine cough syrup, ‘Lean,’ continues to be abused in Texas. —Jane Maxwell
TEXAS:

Exhibit 8.

Primary Admissions for Other Opiate Abuse in 17 CEWG Areas, by Percent of All Admissions (Excluding Alcohol): 2005–20061
42.3 15.3 8.6 7.6 7.4 6.8 6.7 5.5 4.8 3.6 3.2 2.2 1.9 1.9 1.6 1.2 1.1

Maine Brow ard Co.
2

PATTERNS AND TRENDS IN OTHER OPIATE ABUSE ACROSS CEWG AREAS Treatment Data on Other Opiates
In the 2005 and 2006 reporting periods, 18 CEWG areas provided data on admissions for primary abuse of opiates other than heroin. Excluding alcohol, this admissions group accounted for more than 1 percent of illicit drug admissions in 17 (the exception was New York City). These data are depicted in exhibit 8. As shown, the State of Maine exceeded all other areas, with more than 42 percent of illicit drug admissions in 2006 reporting other opiates as their primary drug. Of the 2,282 primary admissions for other opiates, nearly 74 percent were for abuse of OxyContin/oxycodone. In the other 16 areas, the highest proportion of primary other opiate admissions, relative to total admissions, excluding alcohol, was reported from the sample of programs in Broward County, Florida, (15.2 percent), followed by Cincinnati (8.6 percent), Minneapolis/St. Paul (7.6 percent), and Baltimore (7.4 percent). Other opiate admissions as a proportion of all admissions, excluding alcohol, ranged between 6.7 and 6.8 percent in Seattle and Texas.

Cincinnati

3

Mpls./St. Paul Baltimore Texas Seattle Boston Denver Philadelphia Philadelphia Haw aii Hawaii Diego San Diego St. Louis Arizona Detroit
Los Angeles Angeles Chicago Chicago
1

The five areas shown in italic bold reported 2005 data; all others reported data for some period in 2006 data (see Appendix A). 2 The Broward County sample is from 9 programs that serve 51.5 percent of admissions to county treatment facilities. 3 Represents 65–75 percent of the Cincinnati/Hamilton County admissions in the first half of 2006. SOURCES: June 2006 and January 2007 State and local reports

Demographic data. Seven CEWG representatives reported on the demographic characteristics of treatment admissions for primary abuse of opiates other than heroin in 2006. The predominant characteristics are reported for each area. In Baltimore, 53 percent of this admissions group were male, 83 percent were White, and 51 percent were age 35 or older. In Cincinnati, 58 percent were female and 92 percent were White. In Denver, 54 percent of the other opiate admissions were male, 85 percent were White, and 51 percent were age 35 or older. In Detroit, 61 percent of these admissions were female, 80 percent were African-

Proceedings of the Community Epidemiology Work Group, January 2007

35

EPIDEMIOLOGIC TRENDS IN DRUG ABUSE: HIGHLIGHTS AND EXECUTIVE SUMMARY

American, and 78 percent were age 35 or older. The large OxyContin/oxycodone admissions group in Maine was 57 percent male; the group was rather evenly divided between clients in the 24 and younger category and 25–34 age group, at around 39 percent in each age category; 22 percent were 35 or older. Other opiate admissions in St. Louis in the first half of 2006 were 55 percent female and 85 percent White, and they were more likely to be age 26–34 (42 percent) or 35 or older (34 percent). In Texas, 43.5 percent of the other opiate admissions were male, and 82 percent were White. In 2005 in Los Angeles, 39 percent of the other opiate admissions were female, 55 percent were White non-Hispanic, and 49 percent were 36 or older. The Baltimore representative reported a wide range of secondary substances was used by primary other opiate admissions. Similar numbers of treatment admissions reported primary and secondary opiate use. Secondary users were also predominantly White, and a little more than one-half were male. Most reported opiate abuse secondary to heroin injection (33 percent) or intranasal heroin use (21 percent).

percent of the other substances reports. In the other eight CEWG areas, the opiate/opioid reports accounted for between 21 and 29 percent of the total reports.
Exhibit 9a. Number of ED Reports for “Other Substances” and the Percentage of Opiates/Opioid Reports to the Total “Other Substances” Reports in 13 CEWG Areas (Unweighted1): January–June 2006 CEWG Area Boston Chicago Denver Detroit Ft. Lauderdale Houston Miami-Dade Mpls./St. Paul New York City Phoenix San Diego San Francisco Seattle
1

Total Other Substances2 4,583 3,533 1,734 4,176 2,627 3,001 1,342 2,874 5,609 3,414 1,781 1,278 4,219

Percent Opiates/Opioids 29.2 28.0 25.1 32.3 34.6 22.9 21.2 32.6 35.2 24.7 25.8 27.6 36.2

DAWN ED Data on Other Opiates
In the first half of 2006, opiates/opioids reports accounted for substantial percentages of the unweighted “other substances” ED reports in each of the 13 CEWG areas participating in DAWN. The total unweighted number of “other substances” reports for each CEWG area is presented in exhibit 9a, together with the percentage of the opiate/opioid reports in the total for each area. In Detroit, Ft. Lauderdale, Minneapolis/St. Paul, New York City, and Seattle, the unweighted opiate/opioid reports accounted for approximately 32 to 36

All DAWN cases are reviewed for quality control, and based on review, may be corrected or deleted. Therefore, these data are subject to change. 2 Includes prescription drugs (benzodiazepines, opiates/opioids, muscle relaxants), over-the-counter drugs, and dietary supplements; case types include detox, overmedication, and other. SOURCE: DAWN Live!, OAS, SAMHSA, updated 11/17– 11/20, 2006

Unweighted DAWN Live! ED data on opiate/opioid reports for the first half of 2006 are depicted on the map in exhibit 9b and represent the proportion of total opiate/opioid ED reports represented by oxycodone, methadone, hydrocodone, fentanyl, and unspecified opiates/opioids. As can be seen, the category of “opiates/opioids, unspecified” accounts for the largest percentage of reports in Chicago and Detroit and for the second largest percentages in Denver, Ft. Lauderdale, Houston, Miami, New York City, Phoenix,

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Drug Abuse Patterns and Trends Across CEWG Areas: Other Opiates/Narcotic Analgesics

San Diego, San Francisco, and Seattle. Oxycodone reports represent the highest percentages of the opiate/opioid reports in six CEWG areas. Oxycodone reports were especially high in Boston and Ft. Lauderdale, each approximately 48 percent, and they ranged between 29 and 39 percent of the reports in Denver, Miami-Dade County, Minneapolis/St. Paul, and Phoenix. Methadone accounted for 56 percent of the unweighted ED reports in New York City and for 28 and 30 percent of the reports in San Francisco and Seattle, respectively. Hydrocodone reports ranked first in Houston, at 47.5 percent of the unweighted reports, and in San Diego, where they accounted for 31.3 percent of the reports. Hydrocodone reports were also relatively high in Detroit, where they accounted for 27 percent of the unweighted ED reports.

In Cincinnati, there were 47 deaths involving opiates/opioids other than heroin and 10 involving methadone. In Detroit/Wayne County, there were 176 deaths involving fentanyl, 138 involving hydrocodone, 77 with the presence of methadone, and 31 involving oxycodone. In Hennepin/Ramsey Counties, there were 18 deaths involving methadone and 7 involving fentanyl. In Honolulu, there were 10 deaths involving methadone and 37 deaths with the presence of other opiates (excluding heroin). In Miami-Dade County, there were 15 deaths with the presence of morphine, 5 each with the presence of oxycodone or hydrocodone, and 3 involving methadone. In Philadelphia, there were 99 deaths with the presence of codeine, 69 with the presence of methadone, 68 with the presence of oxycodone, 26 with the presence of hydrocodone, and 15 with the presence of propoxyphene. In Seattle/King County, there were 83 deaths involving other opiates.

Mortality Data on Other Opiates
CEWG representatives reported data on deaths involving opiates (other than heroin) in eight local areas and six States. Note that any “total” numbers shown may include decedents who had more than one other opiate (or other type of drug) in their system. Data from metropolitan and county areas are shown below. The data from Detroit/Wayne County and Hennepin and Ramsey Counties in Minnesota are for the first 9 months of 2006; the other six areas reported for the first half of 2006…

In Broward County, Florida, there were 29 deaths involving methadone, 23 involving oxycodone, 9 with the presence of morphine, 6 involving propoxyphene, and 5 related to hydrocodone.

In FY 2006, other opiate deaths in Georgia included 153 involving methadone, 137 involving hydrocodone, 108 involving morphine, 100 involving oxycodone, and 36 involving fentanyl. In the first half of 2006, Florida reported 428 deaths involving methadone, 377 involving oxycodone, and 346 involving hydrocodone. In 2005, Colorado reported 301 deaths involving opiates other than heroin. In Maine in 2005, there were 72 methadone-induced deaths, 17 involving oxycodone, 8 involving propoxyphene, and 7 involving hydrocodone. In Texas in 2005, there were 203 deaths with a mention of methadone, 61 with a mention of oxycodone, 26 with a mention of hydrocodone, and 30 with a mention of fentanyl.
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Drug Abuse Patterns and Trends Across CEWG Areas: Other Opiates/Narcotic Analgesics

In New Mexico from 2003 to 2005, the rate of overdose deaths involving methadone was higher in Albuquerque/Bernalillo County than in the State overall––3.13 versus 2.00 per 100,000 population. The rates for deaths from other opiates were 4.62 and 4.07 for the county and State, respectively.

NFLIS Data on Other Opiates
Across CEWG areas in FY 2006, hydrocodone and oxycodone were the

prescription-type opiate drugs most likely to be identified by forensic laboratories, followed by methadone, codeine, and morphine. The numbers of items by CEWG area are shown in exhibit 10. The exhibit does not include all opiate/opioid items identified by NFLIS but does present the number of items for those most frequently analyzed by forensic labs in 20 CEWG metropolitan areas and the State of Texas.

Exhibit 10. Number of Selected Narcotic Analgesic/Opiate Items Analyzed by Forensic Laboratories in 21 CEWG Areas: FY 2006 CEWG Area Atlanta Baltimore Boston Chicago Cincinnati Denver Detroit Ft. Lauderdale Honolulu Los Angeles Miami Mpls./St. Paul2 New York City Philadelphia Phoenix St. Louis San Diego San Francisco Seattle Wash., DC Texas
1 2

Hydrocodone 333 68 38 113 164 65 NR1 82 11 392 28 75 235 176 45 33 244 168 54 28 1,957

Oxycodone 201 308 153 12 262 80 NR 193 13 55 34 77 239 750 34 51 82 197 78 84 228

Methadone 93 117 23 82 68 10 NR NR 1 32 7 26 509 69 8 23 25 70 36 37 146

Codeine 21 10 10 38 14 15 362 NR 1 104 6 38 74 106 4 24 31 72 6 13 267

Morphine 45 28 39 15 40 10 NR NR 10 37 2 38 43 25 22 10 30 69 6 2 86

NR=Not reported. Data represent primarily the nonmetropolitan areas of Ramsey and Hennepin Counties. SOURCE: NFLIS, DEA

Hydrocodone. In FY 2006, small relatively small numbers of hydrocodone items were reported from 20 CEWG areas. Hydroco-

done was contained in nearly 4 percent of all drug items reported in Texas. In Atlanta, San Francisco, and Seattle, approximately 2

Proceedings of the Community Epidemiology Work Group, January 2007

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EPIDEMIOLOGIC TRENDS IN DRUG ABUSE: HIGHLIGHTS AND EXECUTIVE SUMMARY

percent of all items contained hydrocodone. In the other 16 CEWG areas, hydrocodone was detected in 1 percent or less of all drug items. Oxycodone. In FY 2006, oxycodone accounted for 3.5 percent of all drug items in Ft. Lauderdale, and for approximately 2.0 percent of the items in Boston, Cincinnati, San Francisco, and Seattle. In other CEWG areas, oxycodone represented 1 percent or less of all drug items.

Methadone. New York City and Seattle were the only areas where methadone accounted for as much as 1 percent of total items. Codeine. In 17 areas in FY 2006, codeine accounted for less than 1 percent of all drug items. In Detroit, 8.4 percent of the drug items contained codeine. Morphine. Across 19 CEWG areas in FY 2006, morphine accounted for less than 1 percent of all drug items.

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Proceedings of the Community Epidemiology Work Group, January 2007

Drug Abuse Patterns and Trends Across CEWG Areas: Methamphetamine

Methamphetamine
Methamphetamine abuse indicators continued at high levels in Honolulu, Los Angeles, San Diego, Seattle, Phoenix, Denver, Minneapolis/St. Paul, St. Louis, and Atlanta. However, indicators point to declines in methamphetamine abuse in Atlanta, Denver, Honolulu, Minneapolis/St. Paul, and St. Louis. Indicators were stable in San Francisco. Except for Atlanta, methamphetamine abuse indicators continued to be low in CEWG areas east of the Mississippi River. Indicator data also point to increases in methamphetamine abuse among youth, women, and Hispanics in some CEWG areas. Methamphetamine abuse indicators increased in four CEWG areas where indicator levels have been relatively high.

unweighted DAWN Live! system in the first half of 2006. —Ilene Dode
SAN DIEGO:

Methamphetamine abuse continues to dominate the treatment system. Findings from the Los Angeles County Evaluation System show the proportion of clients admitted for primary methamphetamine use increased from 19.0 percent in 2001 to 36.4 percent in 2005. Primary methamphetamine admissions, excluding alcohol, increased from 23 percent in 2003 to more than 31 percent in 2005. In the 2005 YRBS survey, slightly more females (10.9 percent) than males (9.5 percent) reported lifetime methamphetamine use, but this difference was not statistically significant. Eighty-six percent of the 14 super labs seized throughout the United States from January to June 2006 were located in California; of those, 25 percent were located in LA HIDTA counties. —Beth Rutkowski
LOS ANGELES:

Methamphetamine is the primary illicit drug of abuse in San Diego County, leading all other drugs in most data sources used to assess drug abuse patterns and trends. Methamphetamine was the primary drug of abuse for 49.2 percent of all drug treatment admissions (excluding alcohol) in San Diego County in 2005, up from 45.2 percent in 2004. Methamphetamine was the drug most commonly cited in the unweighted DAWN ED reports involving major illicit drugs in the first half of 2006, and it was the most prevalent illicit drug detected among male (44 percent) and female (51 percent) adult arrestees in 2005. —Robin Pollini

Methamphetamine morbidity and mortality indicators continue to increase, while local manufacturing appears to be continuing its rapid descent. Deaths involving methamphetamine totaled 13, similar to recent years, while treatment admissions continued to increase; 19 percent of clients admitted to treatment reported any methamphetamine use. Excluding alcohol, 18 percent of clients were primary methamphetamine abusers in the first half of 2006, compared with 13 percent in 2003. —Caleb Banta-Green
SEATTLE:
Methamphetamine abuse indicators decreased in five CEWG areas where levels remain relatively high.

Statewide, primary admissions for methamphetamine and other stimulants increased from 24 percent of admissions (excluding alcohol) in FY 2003 to 36 percent in FY 2006. Hospital discharge data continue to show that methamphetamine is the major substance of abuse in Maricopa County. Stimulants accounted for the largest proportion of the major substances of abuse reports (excluding alcohol) in the
PHOENIX:

In Atlanta, methamphetamine abuse indicators decreased in the first half of 2006 for the first time in 10 years. The increased availability of, and reduced cost for, crystal methamphetamine was associated with an 11-percent increase (from FY 2005 to the first half of 2006) in methamphetamine treatment admissions who preferred to smoke to drug. The proportion of items containing methamphetamine in the NFLIS drug seizure data
ATLANTA:
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Proceedings of the Community Epidemiology Work Group, January 2007

EPIDEMIOLOGIC TRENDS IN DRUG ABUSE: HIGHLIGHTS AND EXECUTIVE SUMMARY

for FY 2006 remained stable, while local law enforcement officials reported use of methamphetamine in suburban Atlanta. There are also reports of increases in methamphetamine abuse in AfricanAmerican communities. —Brian Dew
DENVER:

Methamphetamine has exceeded cocaine in statewide treatment admissions since 2003, and in Denver/Boulder treatment admissions since 2005. However, the first half of 2006 showed the first decline in several years for methamphetamine admissions and poison control center calls. Clandestine lab closures have decreased steadily since 2003. The amount of methamphetamine seized increased through 2005, most likely because an estimated 80 percent of Colorado’s methamphetamine comes from outside the State, predominantly Mexico. Drug enforcement officials have reported increased purity levels of methamphetamine seized in Colorado. —Tamara Hoxworth During the first half of 2006, there was a slight decrease in Medical Examiner (ME) reports of positive decedent toxicology for methamphetamine, in primary treatment admissions for methamphetamine abuse, and in methamphetamine cases reported by the Honolulu Police Department. In late 2005, HIDTA reported that both the price and purity of methamphetamine had declined. There was also a small reduction in ME methamphetamine cases in the last half of 2006. Pseudoephedrine is generally not available over the counter in Honolulu, and many drug stores are not ordering antihistamines that contain ephedrine. —D. William Wood

there has been a decline in such abuse in the Twin Cities area. The number of clandestine methamphetamine labs decreased statewide to 59 in 2006 (through November), compared with 112 in 2005 (full year) and 212 in 2004. Adult and youth admissions to addiction treatment programs for methamphetamine abuse declined, falling 37 percent from the last half of 2005 to the first half of 2006. It remains to be seen whether these findings reflect the beginning of a decline in the actual prevalence of methamphetamine abuse, especially among the younger, adolescent population group. —Carol Falkowski In the St. Louis area, methamphetamine abuse treatment admissions decreased 21 percent from the first half of 2005 to the first half of 2006, while statewide treatment admissions increased 4 percent over the same timeframe. Only 53 methamphetamine items (less than 1 percent of all items) were reported by forensic labs in St. Louis. Law enforcement personnel in the St. Louis area continued to devote many resources to methamphetamine, and clandestine laboratory incidents have decreased dramatically since legislation to reduce access to pseudoephedrine-based cold medications was enacted in the summer of 2005. Access to methamphetamine from Mexico and the Southwest is considered to be a major problem confronted by law enforcement agencies in the area. ––James Topolski
ST. LOUIS:
In three States with large rural populations, methamphetamine abuse indicators are increasing, especially in some areas of these States.

HONOLULU:

MINNEAPOLIS/ST. PAUL: Numerous

indicators of methamphetamine abuse declined in 2006, reversing previous upward trends. Collectively, these new data demonstrate that the growth in methamphetamine abuse has slowed and, possibly,

Methamphetamine abuse continues to rise, as indicated by increased arrests from 2005 to 2006. The Maine Drug Enforcement Administration (MDEA) made 8 methamphetamine arrests and seized 4 labs in 2005; in 2006, MDEA made 40 arrests and seized 7 labs. —Marcella Sorg
MAINE:

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Proceedings of the Community Epidemiology Work Group, January 2007

Drug Abuse Patterns and Trends Across CEWG Areas: Methamphetamine

NEW MEXICO: Although

the numbers are relatively small, there has been an increase in ME overdose cases involving methamphetamine, with the rate of methamphetamine overdose deaths per 100,000 population being lower in Bernalillo County than statewide (0.98 vs. 1.44 in 2003–2005). An increasing proportion of methamphetamine treatment admissions reported smoking the drug, from 18 percent in 2001 to 47 percent during January 2004–March 2005. In the first 4 months of 2005, about 10 percent of Albuquerque treatment admissions were primary methamphetamine abusers. Nearly 6 percent of the Albuquerque area students in grades 9–12 reported current (past 30 days) methamphetamine use —Nina Shah Increasingly, ‘ice,’ a higher purity form of methamphetamine, is becoming available in the State. Most of the higher purity ice is produced in Mexico, and local methamphetamine clandestine laboratories are using different ingredients to replace pseudoephedrine, which is becoming more limited in supply. Methamphetamine is a growing problem across the State, and smoking is the major route of administration for methamphetamine abusers entering treatment. In 2006, 53 percent of the primary methamphetamine treatment admissions smoked the drug. These clients tend to have more physical and emotional problems than those who do not smoke the drug. —Jane Maxwell
TEXAS:
Methamphetamine abuse indicators continued at low levels in 10 CEWG areas in the East and Midwest, as shown in the following examples from 5 areas.

samples increased from 17 in 2004 to 55 in 2005 and appeared stable through the first half of 2006. —Daniel Dooley
CINCINNATI: In Cincinnati and the State of Ohio, methamphetamine abuse indicators have remained low and stable. The number of methamphetamine lab seizures recorded by the DEA decreased from 444 in 2005 to 243 in 2006. Methamphetamine abuse indicators stabilized across the State of Ohio, accounting for few treatment admissions. —Jan Scaglione DETROIT: Indicators

for methamphetamine abuse remained low. —Cynthia Arfken

MIAMI: Indicators of methamphetamine abuse remain low, yet criminal cases are rising as high potency ‘Mexican Ice’ is being trafficked into the area via Atlanta into Florida. Sexual activity related to methamphetamine abuse is cited by public health officials as a key factor for MiamiDade and Broward Counties ranking first or second in the Nation in per capita rates of HIV infection. —James Hall PHILADELPHIA:

Methamphetamine abuse indicators continue to be low compared with indicators for other illicit drugs. Methamphetamine abuse is largely confined to a relatively small segment of the population. —Samuel Cutler

There are reports of changing demographics in methamphetamine-abusing populations in 13 CEWG areas, with reports in some areas of increases of abuse among youth, women, and Hispanics.

BOSTON: Methamphetamine

abuse indicators remain very low in Boston. Methamphetamine abuse treatment admissions account for less than 1 percent of all treatment admissions; the number of primary admissions for methamphetamine abuse decreased from 75 in FY 2005 to 31 in FY 2006. Methamphetamine forensic lab

Youth
ATLANTA:

Indicators of methamphetamine abuse among youth have been increasing. ––Brian Dew

DENVER: YRBS data show a decline in methamphetamine use among youth. —Tamara Hoxworth

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EPIDEMIOLOGIC TRENDS IN DRUG ABUSE: HIGHLIGHTS AND EXECUTIVE SUMMARY

LOS ANGELES:

Findings from the 5-year Los Angeles County Evaluation System show that the proportion of 18–25-year-old treatment admissions reporting primary methamphetamine use increased from 31.3 percent to 52.8 percent. —Beth Rutkowski

proportion of female decedents. ––Nina Shah
SAN DIEGO:

MINNEAPOLIS/ST. PAUL:

Treatment admissions for primary methamphetamine abuse among clients younger than 18 declined in the first half of 2006, to 4.5 percent of this admissions group, compared with 11.5 percent in the first half of 2005. —Carol Falkowski
PHOENIX:

The prevalence of methamphetamine use among female arrestees in San Diego increased by 38 percent from 2002 to 2005. —Robin Pollini Hispanics

NEW MEXICO:

At the Treatment Assessment Screening Center from October 2005 to October 2006, there was a slight decrease (about 3–4 percent) in positive methamphetamine (urine) tests among juvenile arrestees. ––Ilene Dode

The most interesting aspect of the increase in methamphetamine overdose deaths from 2003 to 2005 is that, while most were White, there was a growing proportion of Hispanic decedents. ––Nina Shah

The prevalence of methamphetamine use among juvenile arrestees in San Diego increased 75 percent from 2002 to 2005. —Robin Pollini
SAN DIEGO:

The proportion of Hispanics entering treatment for a primary problem with methamphetamine increased from 29 percent in 2000 to 31 percent in 2006, and the term ‘La Tina’ is being heard in Hispanic communities. ––Jane Maxwell
TEXAS:

Women
ATLANTA:

In Atlanta, the proportion of female to male methamphetamine abusers seeking treatment widened in the past 6 months, both in metropolitan Atlanta and in rural areas of the State. About 70 percent of the methamphetamine primary treatment admissions in Atlanta in the first half of 2006 were women. —Brian Dew Findings from the Los Angeles County Evaluation System show that female admissions were more likely to report primary methamphetamine use than males over the entire 5 years of the evaluation. —Beth Rutkowski

PATTERNS AND TRENDS IN METHAMPHETAMINE ABUSE ACROSS CEWG AREAS Treatment Data on Methamphetamine
In the 2006 reporting periods, methamphetamine primary admissions, as a proportion of all admissions, excluding alcohol, continued to be highest in Hawaii (55.2 percent) and Arizona (33.4 percent) Exhibit 11a shows the data from these two areas and seven others where methamphetamine admissions accounted for more than 1 percent of this illicit drug admissions group in 2005 or 2006.

LOS ANGELES:

NEW MEXICO:

Although most methamphetamine overdose deaths from 2003 to 2005 were male, there was a growing

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Proceedings of the Community Epidemiology Work Group, January 2007

Drug Abuse Patterns and Trends Across CEWG Areas: Methamphetamine

Exhibit 11a. Primary Methamphetamine Treatment Admissions in 9 CEWG Areas, by Percent of All Admissions (Excluding Alcohol): 2003–20061 CEWG Area Atlanta Denver Los Angeles Mpls./St. Paul St. Louis San Diego Seattle Arizona Hawaii
1 2

2003 6.9 16.8 23.0 14.8 5.9 NR 13.1 24.1 56.3

2004 11.3 17.6 26.7 19.6 6.5 45.4 15.2 37.5 57.3

20051 15.5 20.7 31.4 22.1 5.7 49.2 16.9 32.5 56.3

2006 11.4 21.8 NR2 15.7 4.6 NR 18.0 33.4 55.2

PercentagePoint Change 2003–2006 4.5 5.0 … 0.9 -1.3 … 4.9 9.3 -1.1

Arizona represents FY 2006; Los Angeles and San Diego are CY 2005; all others are for the first half of 2006 (see Appendix A). NR=Not reported by the CEWG representative. SOURCES: June and January 2007 CEWG reports

In seven other CEWG areas that reported treatment data specifically related to methamphetamine admissions, this group accounted for 1 percent or less of illicit drug admissions in 2005 in Chicago and in the 2006 reporting periods in Baltimore, Boston, Broward County, Florida, Cincinnati, Maine, and New York City. In Philadelphia in the first half of 2006, less than 1 percent of admissions mentioned use of methamphetamine. In San Francisco (FY 2006) and Texas (first half of 2006), methamphetamine was included in a category with amphetamines or “stimulants,” where they accounted for 16.0 and 16.9 percent of illicit drug admissions, respectively. The 2005 treatment data from seven CEWG areas suggest that, compared with cocaine

and heroin admissions, primary methamphetamine admissions are more likely to be female, White, and younger than 25. Gender. In Atlanta, females accounted for 70 percent of the primary methamphetamine admissions in the first half of 2006. In other CEWG areas, males accounted for between 52 (Denver) and 63 (Hawaii) percent of the primary methamphetamine admissions in the 2005 or 2006 reporting periods (see exhibit 11b). Age. Data from 2005 or 2006 show that a majority of primary methamphetamine admissions in five CEWG areas were age 34 or younger. In Atlanta, 81 percent were age 35 or older, and in Seattle, 53 percent were age 30 or older.

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EPIDEMIOLOGIC TRENDS IN DRUG ABUSE: HIGHLIGHTS AND EXECUTIVE SUMMARY

Exhibit 11b. Demographic Characteristics of Primary Methamphetamine Admissions in 8 CEWG Areas, by Percent1: 2005–2006 CEWG Area Atlanta Denver Hawaii Los Angeles Mpls./St. Paul St. Louis San Diego Seattle
1 2

Male 30 52 63 58 62 53 60 60

Gender Female 70 48 37 42 38 47 40 40

White 93 82 14 37 89 98 53 79

Race/Ethnicity Afr.-Amer. Hispanic 4 2 2 13 1 42 3 54 1 4 <1 1 6 32 4 5

Age ≤34 19 70 NR3 72 71 60 58 (see 4) 28 29 40 42 35+ 81 30

Percentages rounded. In Hawaii in 2005, 47 percent of the methamphetamine admissions were “Mixed-Part Hawaiian,” 12 percent were Filipino, 8 percent were “Mixed-Not Hawaiian,” 6 percent were Japanese, and small percentages were members of various other racial/ethnic groups. 3 NR=Not reported by the CEWG representative. 4 In Seattle in the first half of 2006, 44 percent were age 18–20; other age group data were not reported. SOURCES: June 2006 and January 2007 CEWG reports

Race/Ethnicity. In five CEWG areas, Whites constituted the largest majority of primary methamphetamine admissions, ranging from 82 percent in Denver to 98 percent in St. Louis (see exhibit 11b). In San Diego in 2005, 53 percent of this admissions group were White, and 32 percent were Hispanic. In Los Angeles in 2005, 54 percent of the methamphetamine admissions were Hispanic, and 37 percent were White. In Hawaii in 2005, primary methamphetamine abusers were more likely to be part or mixed Hawaiian (47 percent) or members of various racial/ethnic groups.

Route of Administration. Exhibit 11c depicts the routes of administration of methamphetamine among treatment admissions in seven CEWG areas in 2005 or 2006. As shown, smoking was the most frequently reported route of administering methamphetamine in all areas. In 2005, 97 percent of this admissions group smoked the drug in Hawaii, as did 71 and 73 percent in San Diego and Los Angeles, respectively. Injection of methamphetamine was most likely to be reported by admissions in Denver (17 percent) and St. Louis (26 percent) in the first half of 2006.

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Proceedings of the Community Epidemiology Work Group, January 2007

Drug Abuse Patterns and Trends Across CEWG Areas: Methamphetamine

Exhibit 11c. Major Routes of Administration of Methamphetamine Among Treatment Admissions in CEWG Areas, by Percent1: 2005– 20062
7 Atlanta 18 62 13 17 14 66 4 2 <1 97 1 6 Los Angeles Los Angeles 3 14 17 66 3 26 St. Louis 6 14 14 71 1
1 2

Denver

mately 9 percentage points. In Los Angeles from 2003 to 2005, methamphetamine treatment admissions (excluding alcohol) increased more than 8 percentage points. Not shown in exhibit 11a are data from Maine. In Maine, this admissions group accounted for less than 1 percent of illicit drug admissions from 2003 to 2006; however, the number of primary methamphetamine admissions increased from 24 in 2003 to 49 in 2006.

Hawaiiaii Haw

DAWN ED Data on Methamphetamine
Unweighted DAWN Live! data, presented earlier in exhibit 2, show that ED reports for methamphetamine in San Diego exceeded those for other major substances of abuse (excluding alcohol), representing 32 percent of the reports. Methamphetamine accounted for the second highest number of the ED reports in Phoenix (25.5 percent), the third highest number in San Francisco (14.2 percent), and the fourth highest number in Minneapolis/St. Paul (7.2 percent), Seattle (11.8 percent), and Denver (12.0 percent).

18 73 Injection Sniffing/ Intranasal Smoking Other/Multiple/ Unknow n 58

Mpls./St. Paul

11

San Diego San Diego

2

Percentages rounded. Classified as “oral.” SOURCES: June 2006 and January 2007 CEWG reports

Mortality Data on Methamphetamine
The most recent data on deaths with the presence of methamphetamine were reported for six CEWG metropolitan/county areas. The San Diego data are for the year 2005. The data from the Detroit and in Minneapolis/St. Paul areas are for the first 9 months of 2006; in the other three areas, the data are for the first half of 2006. 245 in San Diego County 22 in Honolulu 13 in Seattle/King County

Recent Trends. As shown in exhibit 11a, methamphetamine admissions increased approximately 5 percentage points in Atlanta, Denver, and Seattle when 2003 admissions are compared with those for the first half of 2006. The decrease shown for Atlanta from 2005 to the first half of 2006 is consistent with decreases found in other Atlanta methamphetamine abuse indicators in 2006. The increase from FY 2003 to FY 2006 in Arizona was higher, at approxi-

Proceedings of the Community Epidemiology Work Group, January 2007

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EPIDEMIOLOGIC TRENDS IN DRUG ABUSE: HIGHLIGHTS AND EXECUTIVE SUMMARY

10 in Minneapolis/Hennepin and St. Paul/Ramsey Counties 9 in Philadelphia 9 in Detroit/Wayne County Methamphetamine-involved deaths were also reported for four States. In Texas in 2005, there were 174 death mentions of methamphetamine. In the first half of 2006, Florida reported 58 deaths involving methamphetamine. Georgia reported 85 positive methamphetamine specimens in decedents in FY 2006. The rate of methamphetamine overdose deaths in Albuquerque/Bernalillo County in 2003–2005 was 0.98 per 100,000 population, lower than the State rate of 1.44.

Seizure Data on Methamphetamine
Methamphetamine laboratory seizures (incidents), as reported by DEA’s National Clandestine Laboratory Database, decreased in the nine CEWG States west of the Mississippi River from 2002 to 2005, while they increased in six of the seven States east of the Mississippi. These data are shown on the map in exhibit 12. In areas west of the Mississippi River, laboratory incidents continued to be highest in Missouri, followed by Washington and California. However, the decrease in lab incidents in Missouri from 2002 to 2005 was only 21 percent, compared with 63 and 73 percent in Washington State and California, respectively. Lab incidents decreased 51 percent in both New Mexico and Texas, 65 percent in Minneapolis, 66 percent in Colorado, and 70 percent in Arizona during that period. Seizures in Hawaii continued to be very low, totaling 11 in 2005. East of the Mississippi River, the number of seizures continued to be highest in Illinois, but they decreased 69 percent from 2002 to 2005, when they totaled 931. In Ohio, lab incidents were nearly 2.5 times higher in 2005 than in 2002, rising from 97 to 335. In Pennsylvania, lab incidents were 1.7 times higher in 2005 than in 2002 (80 vs. 31). In Michigan, lab incidents increased 52 percent over the 4-year period, while those in Florida increased 74 percent. A slight increase in lab incidents occurred in Georgia, and a slight decrease was found in New York State.

NFLIS Data on Methamphetamine
As shown earlier on the map in exhibit 3, the proportions of methamphetamine items reported from forensic labs were high in several CEWG areas. Methamphetamine items were the most frequently reported drug items in Honolulu (57.0 percent), Minneapolis/St. Paul (41.3 percent), and Phoenix (31.0 percent). Methamphetamine was the second most frequently identified drug item in San Diego (32.5 percent), Atlanta (29.6 percent), Seattle (28.3 percent), Los Angeles (27.2 percent), and Texas (23.8 percent). In areas east of the Mississippi River, with the exception of Atlanta, 1 percent or less of the items identified by NFLIS contained methamphetamine.

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Drug Abuse Patterns and Trends Across CEWG Areas: Methamphetamine

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EPIDEMIOLOGIC TRENDS IN DRUG ABUSE: HIGHLIGHTS AND EXECUTIVE SUMMARY

Price of Methamphetamine
For mid-year 2006, NDIC reported street prices for several forms of methamphetamine. As shown in exhibit 13, a gram of powder methamphetamine was least expensive in Seattle and most expensive in Bangor, Maine. A gram of ice appeared to be cheapest in Phoenix and most expensive in Honolulu.
Exhibit 13. Methamphetamine Retail (Street) Price1 in 19 CEWG Areas2, Ordered by Lowest Price: June 2006 CEWG Area Seattle Phoenix Wash., DC San Diego Albuquerque San Francisco Dallas Chicago Minneapolis Denver Cincinnati Atlanta New York City Philadelphia Detroit Honolulu Bangor, ME Los Angeles Boston
1 2

Price Per Gram $20–$60 PM3 $40–$50 MX4 Ice5 $40–$150 PM $50–$100 PM $60–$80 MX, LP6 $60–$100 PM $70–$100 PM, LP $80–$100 PM $90–$100 Ice $90–$100 PM, MX, LP $100 PM LP $100–$150 Ice $100–$300 PM $100–$250 PM $125–$175 PM, LP $100–$400 Ice $200 PM Other Quantities $40–$50 1/32 oz MX Ice $400–$500 ¼ oz PM

Most current available price at mid-year 2006. Street-level prices were not available for Baltimore, Miami, or St. Louis. 3 PM=Powder methamphetamine. 4 MX=Mexico-produced. 5 Ice=Ice methamphetamine. 6 LP=Locally produced. SOURCE: NDIC, DOJ

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Proceedings of the Community Epidemiology Work Group, January 2007

Drug Abuse Patterns and Trends Across CEWG Areas: Marijuana

Marijuana
Marijuana continues to be widely available across CEWG areas. Use was especially high among adolescents and young adults, as indicated by treatment data, arrestee data, and survey data. Survey and other data point to high levels of marijuana use, relative to other drugs, among youth and young adults.

quarter of 2006 (75.6 to 76.2 percent). –– Ilene Dode
WASHINGTON, DC:

Marijuana is the most widely available and commonly used drug in New Mexico, especially among teenagers. The 2005 New Mexico Youth Risk and Resiliency Survey showed that high school students in the Albuquerque area were considerably more likely to report past-month use of marijuana than students nationally (30.5 vs. 20.2 percent). ––Nina Shah
ALBUQUERQUE/NEW MEXICO: FLORIDA:

As in past years, juvenile arrestees were more likely to test positive for marijuana than for any other drug in 2006. Over the past several years, approximately 50 percent of the juveniles have tested positive for marijuana. However, there was a steady decrease in the percentages of young arrestees testing marijuana positive from 1999 to 2004. The percentages have leveled off since 2004. ––Erin Artigiani

Primary marijuana treatment admissions increased in five CEWG areas.

In 2006, 11.4 percent of students surveyed statewide reported current (pastmonth) use of marijuana. This represented a 21-percent decrease from 2000 but a 10percent increase from 2005. ––James Hall In the 2005 YRBS survey, approximately 38 percent of female and 42 percent of male students reported lifetime use of marijuana. —Beth Rutkowski

Marijuana remains the most commonly used substance in Atlanta. Treatment admissions for primary marijuana abuse (excluding alcohol) have increased since 2003. Ethnographic reports suggest that marijuana is easily available, and prices for the drug have remained stable. ––Brian Dew
ATLANTA:

LOS ANGELES:

Past-30-day use of marijuana was high among undergraduate students at the University of Minnesota in 2006. Among students of all ages, 37.7 percent of those who used tobacco reported current marijuana use, compared with only 7.8 percent of students who did not use tobacco. Use was highest among students age 18 to 24. ––Carol Falkowski
MINNEAPOLIS/ST. PAUL:

The proportion of juvenile arrestees testing positive for marijuana in the Treatment Assessment Screening Center continued to be high and increased slightly from the third quarter of 2005 to the third
PHOENIX:

Primary marijuana admissions, excluding alcohol, have increased since 2003 and represented 18 percent of admissions (excluding alcohol) in the first half of 2006. In the first half of 2006, 57 percent of primary marijuana admissions reported the use of other substances, primarily alcohol (48 percent), although 10 percent reported cocaine. Some 38 percent were younger than 18, and 81 percent were male. Criminal justice referrals continued to constitute the majority of marijuana treatment admissions—65 percent in the first half of 2006. Marijuana ranked second (after cocaine) in the number of the drug items reported by NFLIS in FY 2006. —Leigh Henderson
BALTIMORE: CHICAGO:

Reported marijuana-related treatment services continued to increase in

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Chicago, though less rapidly than in the rest of the State. ––Lawrence Ouellet
DETROIT:

Treatment admissions for marijuana increased steadily since 2003, accounting for 19 percent of illicit drug admissions in FY 2006…the drug represented one-fifth of the unweighted ED reports for illicit drugs in the first half of 2006, and for 23 percent of the drug items reported by NFLIS in FY 2006. ––Cynthia Arfken Marijuana indicators continued to increase, with treatment admissions increasing 11 percent in the St. Louis area and 21 percent statewide from the first half of 2005 to the first half of 2006. This may be related to a funding issue. —James Topolski

followed a similar trend, but marijuana arrests have continued to decline over the 10-year period. Marijuana arrest data are of little value, since law enforcement is not focusing attention on this drug, except for seizures. ––D. William Wood
MIAMI/FT. LAUDERDALE: Marijuana abuse remains relatively stable at high levels. In the 2005–2006 school survey, current marijuana use increased slightly over the prior year. In the sample of treatment programs in Broward County, primary marijuana admissions (excluding alcohol) decreased from 2005 to the first half of 2006, remaining low in both time periods. In Miami-Dade County, marijuana ranked second after cocaine (excluding alcohol) in unweighted ED reports in the first half of 2006 and in crime lab items in FY 2006. ––James Hall

ST. LOUIS:

Marijuana abuse indicators were mixed but at high or relatively high levels in seven CEWG areas.

Treatment admissions for marijuana have steadily decreased in number and as a proportion of all admissions during the past 7 years. The number of marijuana Helpline calls was unchanged from 2005 to 2006. Marijuana drug arrests (Class D) and forensic lab samples increased in 2005. —Daniel Dooley
BOSTON: DENVER:

Primary marijuana admissions (excluding alcohol) remained relatively stable from 2003 to 2005. However in 2006, marijuana was the most frequently detected drug by the Adult Probation/Parole Department urinalysis tests, ranked second in the NFLIS study, and was third in treatment admissions. ––Samuel Cutler
PHILADELPHIA: SAN DIEGO:

In the Denver area, marijuana abuse (excluding alcohol) has continued to result in the highest number of illicit treatment admissions annually since 1997, but such admissions have remained fairly stable over the past 3 years. There have been decreases in marijuana abuse indicators in other data sources, including the YRBS survey, poison control center call data, and seizure data (amounts of marijuana seized). —Tamara Hoxworth Primary marijuana treatment admissions sharply increased from 1996 to 2005; data for the first half of 2006 suggest the high levels for marijuana admissions will continue. Deaths involving marijuana

Most marijuana indicators are mixed. The proportion of treatment admissions for primary abuse of marijuana (excluding alcohol) decreased slightly from 2004 to 2005 (17.6 vs. 15.2 percent, respectively). In the first half of 2006, marijuana accounted for nearly 22 percent of the illicit ED reports. However, cannabis accounted for 43.5 percent of the drug items reported by NFLIS in FY 2006. ––Robin Pollini

HONOLULU:

TEXAS: Marijuana abuse indicators showed increases in primary marijuana treatment admissions from 2002 to the first half of 2006. During that time frame, the Department of Public Safety lab data showed slight decreases in the percentage of items con-

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taining marijuana. Poison control center calls involving marijuana fluctuated from 2002 to 2005, ranging from 412 to 525. Among treatment admissions in the first half of 2006, those with criminal justice problems continued to be less impaired than those referred from other sources.––Jane Maxwell
Marijuana abuse indicators remained relatively stable at high levels in four CEWG areas.

percent of admissions, excluding alcohol. However, among all persons admitted to treatment in King County from 1999 to the first half of 2006, marijuana was the drug most likely to be reported for ‘any use’ among all admissions, ranging between approximately 48 and 52 percent in each of the 8 years. ––Caleb Banta-Green
Indicators of marijuana abuse decreased in Maine and San Francisco.

CINCINNATI:

Marijuana indicators remain at a high level. Primary marijuana admissions (excluding alcohol) have been relatively stable since 2003 and accounted for 19 percent of illicit treatment admissions during FY 2006. Marijuana submissions reported to NFLIS accounted for 39 percent of the total submissions and for 46 percent of drug items submitted to the Hamilton County Coroner Laboratory. —Jan Scaglione Marijuana indicators, which had been reaching new peaks, seem to have stabilized. —Rozanne Marel

In Maine, marijuana abuse indicators have been decreasing. The decreases appear in treatment admissions data, and in the slight decline in marijuana arrests. Maine youth reported less marijuana use in the 2006 survey than previously. ––Marcella Sorg
MAINE:

NEW YORK CITY:

Marijuana indicators remained high but relatively stable. For most of the years between 2003 and 2006, primary marijuana admissions accounted for approximately 33 to 35 percent of admissions (excluding alcohol) statewide; at three Maricopa County treatment facilities in 2006, the proportions of clients treated for marijuana ranged between 27 and 30 percent (excluding alcohol). Tests positive for marijuana among juvenile arrestees increased slightly in the prior year. The number of marijuana items reported by NFLIS remained relatively stable from 2005 to 2006, at around 31 percent of all drug items. Arizona is becoming the gateway for marijuana smuggling, with 331.3 tons confiscated in FY 2006. ––Ilene Dode
PHOENIX/ARIZONA:

The proportion of treatment admissions in San Francisco County (excluding alcohol) decreased from 13.2 percent in FY 2003 to 10.7 percent in FY 2006. Marijuana arrests decreased 35 percent from 2004 to 2005; arrests dropped 11 percent between the first 4 months of 2005 and the first 4 months of 2006. —John Newmeyer
SAN FRANCISCO:

PATTERNS AND TRENDS IN MARIJUANA ABUSE ACROSS CEWG AREAS Treatment Data on Marijuana
Exhibit 15a presents treatment data on marijuana admissions from 16 CEWG areas for 2006 time periods and from 4 areas where data are available only for 2005. The data represent primary marijuana admissions as a proportion of all admissions, excluding alcohol. In 2006, primary marijuana admissions—relative to total admissions, excluding alcohol—continued to exceed those for any other illicit drug in Denver
53

Treatment admissions for primary abuse of marijuana remained relatively stable from 2004 through the first half of 2006, accounting for approximately 25–28
SEATTLE:

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(38.6 percent), Minneapolis/St. Paul (35.8 percent), and Seattle (25.7 percent); they were essentially equal to the proportion of primary methamphetamine admissions in Arizona. In Atlanta, Cincinnati, Maine, New

York City, St. Louis, Hawaii, and Texas, primary marijuana admissions (excluding alcohol) accounted for between approximately 22 and 31 percent of illicit drug admissions in 2006 reporting periods.

Exhibit 15a. Primary Marijuana Treatment Admissions in 20 CEWG Areas, by Percent of All Admissions (Excluding Alcohol): 2003–20061 CEWG Area/State Atlanta Baltimore Boston Broward Co. (BARC) 2 Chicago Cincinnati 4 Denver Detroit Los Angeles Mpls./St. Paul New York Philadelphia5 St. Louis San Diego San Francisco Seattle Arizona Hawaii Maine Texas
1 2

2003 27.0 17.0 6.7 NR3 NR 29.6 30.2 13.5 16.3 45.0 24.2 23.7 34.4 NR 13.2 32.9 39.6 28.2 33.5 26.5

2004 28.8 16.2 6.6 NR 16.4 30.5 38.6 13.5 17.0 39.1 23.5 22.0 35.1 17.6 11.2 28.2 21.4 25.2 30.5 26.4

2005 27.7 15.8 5.0 16.5 14.7 33.6 37.0 15.4 18.7 32.6 25.3 22.8 29.0 15.2 9.4 25.2 33.5 29.2 25.6 27.1

2006 30.9 18.2 4.2 13.5 NR 27.3 38.6 19.0 NR 35.8 27.8 NR 31.4 NR 10.7 25.7 33.6 28.8 21.7 28.3

PercentagePoint Change 2003–2006 3.9 1.2 -2.5 … … -2.3 8.4 5.5 … -9.2 3.6 … -3.0 … -2.5 -7.2 -6.0 0.6 -11.8 1.8

Represents different time periods (FY 2005 or 2006 or 1H CY 2006, or full year 2005 or 2006, or FY 2006, see Appendix A). NR=Not reported by the CEWG representative. 3 Broward County samples are from 9 programs that serve 51.5 percent of admissions to county treatment facilities. 4 Represents 65-75 percent of the Cincinnati/Hamilton County admissions in the first half of 2006. 5 In the first half of 2006, 26 percent of admissions mentioned use of marijuana. SOURCES: June 2006 and January 2006 CEWG reports

Gender. In 16 CEWG areas reporting on the gender of primary marijuana admissions, males predominated in each area (see exhibit

15b). The areas with the highest proportions of female marijuana admissions were Atlanta and Cincinnati, each at 35 percent.

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Exhibit 15b. Demographic Characteristics of Primary Marijuana Treatment Admissions in Reporting CEWG Areas, by Percent1: 20052–2006
Gender CEWG Area Atlanta Baltimore Boston Chicago Cincinnati Denver Detroit Los Angeles Maine Mpls./St. Paul New York Philadelphia St. Louis San Diego Seattle Texas
1 2

Male 65 81 73 77 65 75 73 72 74 80 78 83 73 73 75 70

Female 35 19 27 23 35 25 27 28 26 20 22 17 27 27 25 30

Race/Ethnicity Afr.White Hispanic Amer. 37 56 4 45 21 7 36 46 3 14 61 7 19 42 43 44 32 52 52 76 64 20 94 30 NR 26 60 60 56 20 31 22 5 29 10 1 32 8 44 2 22 15 NR 30 2 51

Age <17 (20) 10 38 64 18–25 3 40 24 NR3 NR 40 29 50 33 38 NR4 25 38 404 27 25 23 30 34 NR 34 24 37 NR 21 28 13 20 15 NR 25 19 20 12 18 13 18 13 22 17 18 3 26–34 6 14 24 35+ 81 9 12

53 (30 or younger)5

Percentages rounded. The four areas reporting 2005 data are shown in italic bold. 3 NR=Not reported by the CEWG representative. 4 New York reports for “24 and younger” (45 percent) and 25–34 (33 percent), and Seattle reports “18 and younger.” 5 Philadelphia reports: <21 (8 percent); 21–25 (28 percent); 26-30 (19 percent); 31–35 (13 percent); and 36+ (shown above). SOURCES: June 2006 and January 2007 CEWG reports

Race/Ethnicity. African-Americans accounted for one-half or more of primary marijuana admissions in 8 of 15 reporting CEWG areas, with the proportions being highest in Chicago and Detroit (76–94 percent) (see exhibit 15b). Whites accounted for 61 percent of the marijuana admissions in Minneapolis/St. Paul and for the largest proportions in Denver, San Diego, and Seattle. Hispanics ranked first in Los Angeles (51 percent) and Texas (44 percent) and ranked second in Boston, Chicago, Denver, New York City, and San Diego. Age. Primary marijuana admissions tended to be younger than admissions for other drugs across 12 reporting CEWG areas. However, there was more variation across the marijuana age groups than was the case for other drugs. As shown in exhibit 15b, marijuana admissions age 17 and younger accounted for the largest proportion in

Boston (64 percent), Denver (40 percent), and Los Angeles (50 percent), and slightly exceeded admissions for the 18–25-year-old group in Minneapolis/St. Paul and Seattle. In Atlanta, marijuana admissions were most likely to be 35 or older (81 percent). Six CEWG areas reported on the mode of administration among primary marijuana admissions. The percentages who smoked marijuana ranged from 92 in Denver to 97 in Baltimore, Maine, and New York City. In St. Louis, 94 percent smoked the drug, as did 95 percent of the marijuana admissions in Atlanta. In the 2006 reporting periods, four CEWG areas reported on secondary drug use among primary marijuana admissions. Among primary marijuana admissions who used a second drug, alcohol was the most frequent-

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ly reported secondary drug in Baltimore, Detroit, New York City, Minneapolis/ St. Paul, and St. Louis. The proportions reportedly using alcohol were 48 percent in Baltimore, 26 percent in St. Louis, and nearly 71 percent in Minneapolis/St. Paul. In 2005, Boston and Los Angeles reported that alcohol was the secondary drug most frequently used by marijuana admissions. Recent Trends. Of the 15 CEWG areas for which 2003 and 2006 data were reported (see exhibit 15a), primary marijuana admissions as a proportion of total admissions, excluding alcohol, increased between approximately 6 and 9 percentage points in Detroit and Denver, respectively. Decreases of more than 6.0 percentage points or more were reported for Arizona (6.0 percentage points), Seattle (7.2), Minneapolis/St. Paul (9.2), and Maine (11.8). In the other nine CEWG areas, the proportions of primary marijuana admissions (excluding alcohol) were relatively stable, increasing or decreasing less than 4 percentage points.

Mortality Data on Marijuana
The presence of marijuana in decedents is not tested in all CEWG areas. In the first half of 2006, Honolulu reported 26 deaths with the presence of marijuana, and the Cincinnati/ Hamilton County ME reported 2 such deaths. In Florida in the first half of 2006, 471 deaths with the presence of marijuana were reported. In FY 2006 in the State of Georgia, mortality data show there were 102 positive drug-type specimens for the THC metabolite; these accounted for 5.1 percent of the positive type specimens.

NFLIS Data on Marijuana
Across CEWG areas in FY 2006, the proportions of cannabis/THC items were higher than those for other drug items in Boston and Chicago, where they accounted for approximately 44 and 50 percent of the items reported by NFLIS (see the map shown earlier in exhibit 3). In Baltimore, Washington, DC, Philadelphia, St. Louis and Cincinnati, between 31 and 39 percent of all drug items contained cannabis. In Honolulu, Miami, Denver, Detroit, Los Angeles, New York City, Phoenix, San Francisco, and Texas, cannabis was found in 20 to 29 percent of all drug items. Except for heroin items, cannabis items were low compared with other drug items reported in Atlanta (2.2 percent), Ft. Lauderdale (12.4 percent), and Minneapolis/St. Paul (14.3 percent).

DAWN ED Data on Marijuana
Unweighted DAWN Live! data for the first half of 2005 in 13 CEWG areas were presented earlier in exhibit 2. Marijuana reports were the second most frequently recorded major substance of abuse (excluding alcohol) in six CEWG areas. Marijuana accounted for between 30.3 and 36.5 of the illicit drug reports in Houston and Minneapolis/St. Paul, respectively (see the map in exhibit 2). The proportions were lower in San Diego (21.7 percent), Denver (24.0 percent), Miami (25.4 percent), and Ft. Lauderdale (29.5 percent).

Price Data on Marijuana
The price of different forms of marijuana continued to vary across CEWG areas. The price per gram was higher in Honolulu than

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in the other eight areas shown in exhibit 16. Typically a “joint” or “cigarette” could be purchased for $5 to $10 dollars in Albuquerque, Boston, Denver, and San Francisco. Note the higher prices for the sinsemilla and hydroponic forms of the drug in Seattle.
Exhibit 16. Marijuana Retail (Street) Price1 in 18 2 CEWG Areas, Ordered by Lowest Price: June 2006 Price Per Gram $5–$7 MX3 $5–$7 CG4 $5–$10 $5–$10 MX $10 CG $10 CG $10 CG $10 CG $20–$30 DO5 Other Prices Albuquerque Boston Denver San Francisco San Diego New York City Philadelphia Bangor, ME Seattle
1 2

CEWG Area Chicago Minneapolis Baltimore Los Angeles Atlanta Dallas Detroit Wash., DC Honolulu

$5 per joint $5 per joint $5 per joint $5–$10 per cigarette $10 per bag (1–3 oz) MX $10–$20 per bag CG $25 per 1/8 oz CG $30 per 1/8 oz $40–$50 per 1/8 oz SN6, HY7

Most current available price at mid-year 2006. Street-level prices not available for Miami, Phoenix, or St. Louis. 3 MX=Mexico-produced. 4 CG=Commercial-grade. 5 DO=Domestic. 6 SN=Sinsemilla. 7 HY=Hydroponic. SOURCE: NDIC, DOJ

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Club Drugs (MDMA, GHB/GBL, LSD, Ketamine)
The club drugs in this section include MDMA (methylenedioxymethamphetamine, or ecstasy), GHB (gamma hydroxybutyrate), GBL (gamma butyrolactone), lysergic acid diethylamide (LSD), and ketamine. While these drugs continue to be used at “raves” and in other party settings, data indicators continue to suggest that use of GHB, LSD, and ketamine is quite low in most CEWG areas. MDMA continues to be the most widely used of the club drugs, but its use/misuse is also relatively low.
Indicators of abuse of club drugs from several CEWG areas indicate that these drugs, particularly MDMA, continue to be abused, especially among young people. Levels of MDMA abuse were low and stable in most areas; however, increases among some populations, or in some MDMA indicators, were reported in Atlanta, Chicago, Miami/Ft. Lauderdale, Seattle, and Texas. In Detroit and Seattle, there were reports of MDMA being smuggled from Canada, and in Seattle and South Florida, there were reports of the drug being produced locally.

low potency or bogus MDMA. Pills are branded with logos, and, though the different logos reappear in markets, a single logo normally is not steadily available from any one dealer. ––Lawrence Ouellet
MIAMI/FT. LAUDERDLE: While MDMA abuse indicators stabilized from 2002 to 2003, the 2006 data show increases. There were increases in the number of MDMA items analyzed by forensic labs and in deaths related to MDMA. Also, the 2005– 2006 survey of middle and high school students points to an increase in current (past-month) use among youth. In 2000, 2.8 percent of students surveyed reported current use; the figure dropped to 1.0 percent in 2005 but increased to 1.2 percent in 2006. The DEA reported that MDMA precursors were being sold out of mom and pop clandestine labs. ––James Hall

Customs data show an increase in MDMA dosage units seized. Most of the MDMA is coming into the State from Canada, but there are reports that it is being produced locally as well. ––Caleb BantaGreen
SEATTLE:

Indicators of increases in MDMA abuse among youth and/or African-Americans were reported in the following CEWG areas:

Atlanta:

In Atlanta, MDMA abuse is continuing to increase in African-American communities. ––Brian Dew Increases in MDMA abuse have been reported among lower income AfricanAmerican youth. In some street drug markets, MDMA is routinely available along with the usual staples of heroin and crack cocaine. The typical price is $20 per pill, but $10 pills of low potency have been reported. Users often perceive three classes of MDMA: 1) MDMA that is cut with heroin, 2) MDMA that is cut with cocaine, and 3)

CHICAGO:

Indicators of ecstasy use are increasing as the drug spreads from the White club scene to a diverse racial/ethnic population. Treatment data show a 30percent increase in MDMA use among African-American admissions. Texas Poison Control Centers reported 23 calls involving misuse or abuse of ecstasy in 1998… 119 in 2000… 172 in 2002… 302 in 2004, and 343 in 2005. In 2005, the average age of callers was 21.—Jane Maxwell
TEXAS:
Examples of data from CEWG areas where MDMA indicators were low and stable are as follows:

BOSTON:

Levels of MDMA abuse continue to be low, as indicated by forensic lab and Helpline data for 2006. ––Daniel Dooley

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Epidemiologic indicators for MDMA indicate limited use across the Cincinnati area in 2006. There were 16 intentional exposure calls to poison control in 2005 involving MDMA and 7 in 2006; calls involving GHB totaled 1 in 2005 and 5 in 2006 (these unconfirmed data are from 38 of 88 counties in Ohio). ––Jan Scaglione
CINCINNATI: DETROIT: Ecstasy use is still troublesome, as evidenced by treatment admissions and medical examiner reports. There were three poison calls related to MDMA in the first 9 months of 2006. MDMA is being smuggled in from Canada, but there are no signs of a real surge in abuse. ––Cynthia Arfken

ecstasy totaled 45. There were two admissions each for primary abuse of GHB and ketamine. —Jane Maxwell

DAWN ED Data on Club Drugs
Unweighted DAWN Live! data for the first half of 2006 show that MDMA was the most frequently reported club drug in all 13 CEWG areas (see exhibit 17). LSD (unweighted) reports tended to be second in frequency among these four drugs. A small number of (unweighted) ED reports were shown for GHB in all 13 areas. Ketamine ED reports were few in number and were documented in only 10 of the 13 CEWG areas.
Exhibit 17. Numbers of MDMA, GHB, LSD, and Ketamine ED Reports in 13 CEWG Areas (Unweighted1): January–June 2006
CEWG Area Boston Chicago Denver Detroit Ft. Lauderdale Houston Miami-Dade Mpls./St. Paul New York City Phoenix San Diego San Francisco Seattle
1

PATTERNS AND TRENDS IN ABUSE OF CLUB DRUGS ACROSS CEWG AREAS Treatment Data on Club Drugs
Two CEWG areas reported 2006 data on primary abuse of one or more club drugs among treatment admissions. In addition, Chicago reported 2005 data for the overall category of “club drugs.” In FY 2005, there were 76 admissions for primary abuse of club drugs; most were male (92 percent) and AfricanAmerican (74 percent). The 2005 admissions represent an increase over the 30 club drug admissions in FY 2004. —Lawrence Ouellet
CHICAGO:

MDMA 72 67 41 101 51 97 47 63 90 30 29 62 72

GHB 9 7 7 7 9 2 2 3 21 6 3 17 12

LSD 10 6 14 13 10 13 15 28 15 8 7 28 26

Ketamine 5 1 3 1 0 0 1 0 11 5 1 5 1

There were 10 admissions for primary abuse of ecstasy in Detroit/Wayne County in 2006. —Cynthia Arfken
DETROIT:

All DAWN cases are reviewed for quality control. Based on the review, cases may be corrected or deleted. Therefore, these data are subject to change. SOURCE: DAWN Live!, OAS, SAMHSA, updated 11/17– 11/20, 2006

In the first half of 2006, admissions to treatment for a primary problem with
TEXAS:

The unweighted MDMA ED reports constituted 1 percent or less of the ED reports in Chicago, Ft. Lauderdale, Miami, New York City, and Phoenix. In the other

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eight CEWG areas, MDMA accounted for between 1.2 percent (Seattle) and 2.4 percent (Houston) of the reports. (See Appendix B-2 for the total number of major substances of abuse reports, excluding alcohol, in each CEWG area.)

MDMA. MDMA was the club drug most frequently reported by forensic labs in the 21 CEWG areas depicted in exhibit 18. As shown, MDMA exceeded 2 percent of all drug items only in Atlanta, Denver, Minneapolis/St. Paul, St. Louis, San Francisco, and Seattle.
Exhibit 18. Number of MDMA Items and Percentage of MDMA to Total Items Reported by Forensic Labs in 21 CEWG Areas: FY 2006
MDMA Items Number 847 109 27 519 91 177 5 84 41 606 217 182 254 112 51 283 196 251 100 122 956 Percent 5.0 0.2 0.4 0.8 0.6 2.7 0.1 0.9 1.7 1.1 1.2 2.5 0.5 0.4 0.8 4.7 0.9 2.3 3.2 1.6 1.7

Mortality Data on Club Drugs
Deaths with the presence of one or more club drugs were reported from the following five CEWG areas:

CEWG Area Atlanta Baltimore Boston Chicago Cincinnati Denver Detroit Ft. Lauderdale Honolulu Los Angeles Miami Mpls./St. Paul New York City Philadelphia Phoenix St. Louis San Diego San Francisco Seattle Washington, DC Texas NFLIS, DEA

In Detroit/Wayne County in the first 9 months of 2006, there were 11 deaths involving MDMA and 4 involving ketamine. In Florida in the first half of 2006, there were 25 deaths related to MDMA, 18 involving methylenedioxyamphetamine (MDA), and 3 involving GHB; deaths involving MDMA and MDA increased 56 and 50 percent, respectively, from the second half of 2005. In Georgia in FY 2006, there were 20 deaths with positive screens for MDMA. In Philadelphia in the first half of 2006, there were 7 deaths with the presence of MDMA; 59 such deaths were reported since 1994. In Texas in 2005, there were 11 death certificates with a mention of MDMA.

NFLIS Data on Club Drugs
In FY 2006, a total of 4,696 reports of the 4 club drugs were reported from 20 CEWG metropolitan areas, and another 1,082 were reported from Texas forensic laboratories. The data on each of these drugs follow.

Ketamine. Ketamine was the second most frequently reported drug item in the NFLIS FY 2006 data. Ketamine items were reported from all areas except Detroit, Honolulu, Philadelphia, and Seattle. Ketamine accounted for less than 1 percent of the total drug items in all 17 reporting CEWG areas. LSD. In FY 2006, LSD was the third most frequently reported club drug and was

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reported in 17 metropolitan CEWG areas. LSD was not among the top 25 drug items reported from the State of Texas, and no LSD items were reported from Baltimore, Honolulu, and Philadelphia. The number of LSD items in all 17 reporting areas was small, accounting for less than 1 percent of the total drug items. GHB. Items containing GHB were reported from nine CEWG areas in FY 2006, including Texas. In all nine areas, GHB items accounted for less than 1 percent of the total drug items.

Exhibit 19. MDMA Retail (Street) Price1 in CEWG Areas,2 Ordered by Lowest Price: June 2006 CEWG Area Minneapolis Philadelphia Los Angeles New York City Honolulu Dallas San Diego Detroit Atlanta Chicago Albuquerque Denver San Francisco Seattle Bangor, ME St. Louis Miami Wash., DC Boston
1 2

Price Data on MDMA
As shown in exhibit 19, the low end retail (street) price of an MDMA dosage unit in mid-2006 was cheapest in Minneapolis and Philadelphia, at $5 and $8, respectively. The low end price of $20 per tablet/dosage unit was consistent across eight CEWG areas––Denver, San Francisco, Seattle, Bangor, St. Louis, Miami, Washington, DC, and Boston.

Price Per Tablet/ Dosage Unit $5–$45 $8–$35 $10–$15 $10–$35 $10–$40 $12–$20 $15–$18 $15–$28 $15–$30 $15–$30 $17–$25 $20 $20 $20 $20–$25 $20–$25 $20–$30 $20–$30 $20–$40

Most current available price at mid-year 2006. Prices not available for Baltimore, Cincinnati, or Phoenix. SOURCE: NDIC, DOJ

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Phencyclidine (PCP)
The most recent indicator data suggest that PCP is not a major problem in any CEWG area, although indicators of PCP abuse continue to be higher in Los Angeles, Philadelphia, and Washington, DC, than in other areas.

BALTIMORE:

In 2005, there were three calls to the Baltimore poison control center involving PCP. ––Leigh Henderson Whether PCP is reversing the trend and increasing in St. Louis/Missouri is a question to be addressed in the future. ––James Topolski

ST. LOUIS:

Among adult arrestees tested in the Pretrial Services Agency, positive tests for PCP have fluctuated over the years, peaking in 2001–2003, decreasing in 2004, and increasing again in 2006. From January through November 2006, 10 percent of adult arrestees and 3 percent of juvenile arrestees tested positive for PCP. The drug continues to be used with marijuana in blunts. Key informants from criminal justice and public health identified PCP as one of the greatest drug threats in the area. ––Erin Artigiani
WASHINGTON, DC:

admissions (n=128) in the latter half of 2005. The proportion of PCP admissions among all admissions has been stable for several years, but the overall number of PCP admissions has fluctuated since the late 1990s. From 1999 to the first half of 2003, the number of admissions increased 89 percent. In the second half of 2003, however, the number of PCP admissions decreased slightly (16 percent) to 262 admissions, and it continued to decrease further (12 percent) in the first half of 2004 to 230 admissions and in the second half of 2004 to 135 admissions (41 percent decrease from the first half of the year). In the first half of 2005, there was a very slight upturn in the number of PCP admissions, representing an 11-percent increase in number. But in the second half of 2005, the number decreased again (7 percent) to 128 admissions. Alcohol (22 percent), cocaine/ crack (20 percent), and marijuana (18 percent) were the three drugs most frequently reported as secondary drugs among primary PCP admissions. An overwhelming majority (98 percent) of the primary PCP admissions smoked the drug. About 1 percent reported oral ingestion or inhalation (snorting). —Beth Rutkowski
PHILADELPHIA: Mentions of PCP use at admission to treatment declined precipitously from 2004 to 2005 [from 563 to 347]. African-Americans accounted for 43.6 percent of PCP treatment admissions in 2005, followed by Whites (16.7 percent), Hispanics of any race (16.2 percent), and Asians and others (23.6 percent). Nearly 86 percent were male, and 58 percent were age 30 or younger. —Samuel Cutler

PCP abuse indicators are stable or rising. ––Jane Maxwell
TEXAS:

PATTERNS AND TRENDS IN PCP ABUSE ACROSS CEWG AREAS Treatment Data on PCP
PCP is often combined with “other drugs” or a “hallucinogens” category in treatment data sets. Two CEWG areas that reported 2005 data specific to treatment of PCP abuse are cited below, together with PCP treatment data from Texas for the first half of 2006.
LOS ANGELES:

Adolescent and adult admissions to treatment with a primary problem with PCP have varied over time, rising from 164 in 1998 to 417 in 2003 and then dropping to 223 in 2005. In the first half of 2006, there were 99 admissions for primary abuse of PCP. —Jane Maxwell
TEXAS:

Primary PCP treatment admissions accounted for 0.5 percent of all

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DAWN ED Data on PCP
As shown in exhibit 20, there were only three CEWG areas where unweighted PCP reports constituted more than 1 percent of the total ED reports for all major substances of abuse (excluding alcohol): San Francisco (1.1 percent), New York City (1.3 percent), and Houston (5.0 percent).
Exhibit 20. Number of ED Reports for PCP and Percentage of Total Major Substances of Abuse (Excluding Alcohol) in 13 CEWG Areas (Unweighted1): January–June 2006
(n=)

reported 42 PCP-involved deaths in the first 9 months of 2006. Philadelphia reported 42 deaths with the presence of PCP in the first half of 2006. Seattle reported that there were no mentions of PCP (or LSD) in any druginvolved deaths in the first half of 2006.

NFLIS Data on PCP
In FY 2006, 11 metropolitan areas and Texas reported some number of PCP items identified by forensic labs in their areas. The largest numbers of items were reported from the five CEWG areas shown in exhibit 21. PCP accounted for 3.4 percent of the items identified by forensic labs in Washington, DC, for 1.9 percent of the items identified in Philadelphia, and for 1.0 percent of those reported from New York City. In Chicago and Los Angeles, PCP was found in less than 1 percent of the total drug items.
Exhibit 21. PCP Items Reported by Forensic Laboratories in 5 CEWG Areas, Ordered from Highest to Lowest Number: FY 2006
Philadelphia New York City Los Angeles Wash., DC Chicago 76 257 328 518 479

Boston (13) Chicago (35) Denver (13) Detroit (5) Ft. Lauderdale (4) Houston (200) Miami-Dade (4) Mpls./St. Paul (19) New York City (186) Phoenix (21) San Diego (16) San Francisco (39) Seattle (43)
1

0.2% 0.4% 0.5% 0.1% 0.1% 5.0% 0.1% 0.5% 1.3% 0.7% 0.8% 1.1% 0.7%

SOURCE: NFLIS, DEA

All DAWN cases are reviewed for quality control and, based on review, may be corrected or deleted. Therefore, these data are subject to change. SOURCE: DAWN Live!, OAS, SAMHSA, updated 11/17– 11/20, 2006

Mortality Data on PCP
Three CEWG representatives reported on deaths with the presence of PCP. Detroit

In Baltimore, Boston, Phoenix, St. Louis, San Diego, and Seattle, between 6 and 24 PCP items were reported, representing less than 1 percent of the total drug items analyzed in these six metropolitan areas. Across the State of Texas, 128 of the total items contained PCP, accounting for less than 1 percent of all drug items analyzed by the Department of Public Safety labs.

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EPIDEMIOLOGIC TRENDS IN DRUG ABUSE: HIGHLIGHTS AND EXECUTIVE SUMMARY

Benzodiazepines/ Depressants
Benzodiazepine abuse indicators are relatively high in CEWG areas and seemed to be increasing in some. Deaths with the presence of benzodiazepines are high in such areas as Georgia, Philadelphia, South Florida, and Seattle, attesting to the serious consequences of misuse and abuse of this class of pharmaceuticals. Alprazolam and clonazepam continue to be the most frequently reported benzodiazepines in indicator data.

pharmaceutical/non-controlled drug items recorded by NFLIS in FY 2006. ––Beth Rutkowski Among drugrelated deaths locally and statewide, alprazolam (Xanax) is the most frequently cited benzodiazepine related to nonmedical use. Alprazolam continued to constitute most of the benzodiazepine-related deaths statewide in the first half of 2006. The system is lax in terms of diversion, especially of benzodiazepines, but also for other non-prescribed pharmaceuticals. Xanax is relatively cheap, at about $5 for a 10-milligram pill that can be split for more than one dose. The numbers of deaths, ED reports, and crime lab items related to the non-medical use of benzodiazepines in Broward County are more than double the numbers in MiamiDade County. ––James Hall
MIAMI/FT. LAUDERDALE:

ATLANTA: Alprazolam (Xanax) continues to be the most popular benzodiazepine and ranked fourth in the number of drug items reported by NFLIS in FY 2006. ––Brian Dew BOSTON: Benzodiazepine misuse and abuse levels remain fairly stable at relatively high levels. —Daniel Dooley

Benzodiazepine-related calls to the Illinois Poison Center in Chicago repeatedly represented nearly one-half of all substance misuse calls between 2001 and 2005. Approximately 500–600 calls annually were reported during this time period. —Lawrence Ouellet
CHICAGO: CINCINNATI:

Benzodiazepines remained a problem across the area. In 2006, there were 116 calls to the poison center related to alprazolam, 168 related to clonazepam, and 65 related to diazepam. The number of benzodiazepine cases seems to be much higher than those for other pharmaceuticals. Xanax tops the list for desirability and also prescriptions among people who get them for legitimate reasons. ––Jan Scaglione

The two most frequently abused benzodiazepines continue to be alprazolam and diazepam, although others are abused/misused. As a group, benzodiazepines were the second most frequently detected drugs in decedents in the first half of 2006 and ranked fourth in the NFLIS study. Benzodiazepines ranked sixth among drugs of abuse mentioned by clients in treatment during the same time period. —Samuel Cutler
PHILADELPHIA:

Benzodiazepine-related deaths have increased steadily in King County since 1999 and totaled 26 in the first half of 2006. ––Caleb Banta-Green
SEATTLE:

Prescription benzodiazepines are second only to cocaine in the number of substance-related deaths across Georgia. —Brian Dew
GEORGIA: LOS ANGELES:

Abuse of alprazolam (Xanax) is increasing (as in the abuse of Soma). In 2006, the calls related to alprazolam increased 4.5 percent from the previous year, those involving clonazepam increased 0.9 percent, and those involving diazepam increased 0.6 percent. —Jane Maxwell
TEXAS:

Analgesics and benzodiazepines accounted for 71 percent of the

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Drug Abuse Patterns and Trends Across CEWG Areas: Benzodiazepines

PATTERNS AND TRENDS IN BENZODIAZEPINE/DEPRESSANT ABUSE ACROSS CEWG AREAS Treatment Data on Benzodiazepines
While treatment data on benzodiazepines are included in other drug categories in most CEWG areas, the numbers of admissions in the combined categories are small, typically less than 1 percent (e.g., in Atlanta, Denver, Hawaii, San Diego, Seattle, and Texas). The most recent reports (2005–2006) show that benzodiazepines accounted for only small percentages of admissions in the reporting areas.
BALTIMORE: Treatment admissions for benzodiazepines and other tranquilizers were between 5.0 and 8.0 admissions per 100,000 population age 12 and older from 2001 to 2005. —Leigh Henderson

DAWN ED Data on Benzodiazepines
In the 13 CEWG areas participating in DAWN in the first half of 2006, benzodiazepines accounted for a substantial percentage of “other substances” reports. Exhibit 22a presents the total unweighted numbers of “other substances” and the percentages that benzodiazepines represented in that total in each CEWG area in the first half of 2006. As shown, the proportions of (unweighted) benzodiazepines as a percentage of the total “other substances” reports varied by CEWG area. These reports accounted for approximately 30–37 percent of the other substances reports in Houston, Miami-Dade, and Ft. Lauderdale, and for between 13 and 24 percent in the other 10 CEWG areas.
Exhibit 22a. Number of ED Reports for “Other Substances” and the Percentage of Benzodiazepines Reports Among the Total “Other Substances” Reports in 13 CEWG Areas (Unweighted1): January–June 2006 CEWG Area Boston Chicago Denver Detroit Ft. Lauderdale Houston Miami-Dade Mpls./St. Paul New York City Phoenix San Diego San Francisco Seattle
1

Excluding alcohol, admissions for primary abuse of benzodiazepines accounted for 2.3 percent of clients (n=57) at Broward Addiction Recovery Center (BARC) programs in the first half of 2006. In the first half of 2006, there were 440 primary, secondary, or tertiary mentions of benzodiazepines, accounting for 8.3 percent of total mentions, excluding alcohol. —James Hall
BROWARD COUNTY, FL:

In 2006, 1 percent of treatment admissions, excluding alcohol, were for primary abuse of benzodiazepines. Thirtyfive percent were female, and 85 percent were equally divided between the 25–34 and 35-and-older age groups. ––Marcella Sorg
MAINE:

Total Other Substances2 4,583 3,533 1,734 4,176 2,627 3,001 1,342 2,874 5,609 3,414 1,781 1,278 4,219

Percent Benzodiazepine 23.8 17.2 16.4 17.7 37.1 30.0 34.2 13.5 17.5 17.9 18.7 16.8 17.0

In the first half of 2006, benzodiazepines accounted for 2 percent of the mentions among treatment admissions and ranked fifth among drug mentions. —Samuel Cutler
PHILADELPHIA:

All DAWN cases are reviewed for quality control and, based on review, may be corrected or deleted. Therefore, these data are subject to change. 2 Includes prescription drugs (benzodiazepines, opiates/opioids, muscle relaxants), over-the-counter drugs, and dietary supplements; case types include “Seeing Detox,” “Overmedication,” and “Other.” SOURCE: DAWN Live!, OAS, SAMHSA, updated 11/17– 11/20, 2006

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EPIDEMIOLOGIC TRENDS IN DRUG ABUSE: HIGHLIGHTS AND EXECUTIVE SUMMARY

In all 13 CEWG areas reporting to DAWN, substantial percentages of the unweighted benzodiazepine reports were overmedication cases (see exhibit 22b). In Phoenix, nearly 51 percent of the benzodiazepine reports were for overmedication, as were approximately 44 and 45 percent of those in San Diego and San Francisco, respectively, and 30–37 percent of those in Chicago, Detroit, and Denver.
Exhibit 22b. Number of ED Reports for Benzodiazepines (B) and Percent for Overmedication in 13 CEWG 1 Areas (Unweighted ): January–June 2006 CEWG Area Boston Chicago Denver Detroit Ft. Lauderdale Houston Miami-Dade Mpls./St. Paul New York City Phoenix San Diego San Francisco Seattle
1

data are for FY 2006; data from all other areas are for the first half of 2006.

Arizona—34 benzodiazepine-involved deaths Broward County, Florida – 128 alprazolam-related deaths; 51 were alprazolam induced, and only 3 involved alprazolam alone – 76 diazepam-related deaths; 21 were diazepam induced, and 61 involved at least 1 other drug Florida—2,080 benzodiazepine-involved deaths – 1,057 alprazolam-related deaths – 608 diazepam-related deaths Georgia—257 alprazolam-related deaths Miami-Dade County – 41 alprazolam-related deaths; 10 were alprazolam induced, and 33 involved at least 1 other drug – 11 diazepam-related deaths; 1 was caused by the drug, and 9 involved at least 1 other drug Philadelphia – 77 detections of diazepam, making it the 4th most frequently detected drug since 1994 – 68 detections of alprazolam, making it the 11th most frequently detected drug since 1994 Seattle/King County—44 benzodiazepine-involved deaths

Number B Reports2 1,089 609 284 739 975 900 459 388 981 611 333 215 716

Percent Overmedication 25.3 30.4 37.0 34.4 18.0 20.8 26.6 26.3 16.1 50.7 43.8 44.7 24.2

• •

All DAWN cases are reviewed for quality control and, based on review, may be corrected or deleted. Therefore, these data are subject to change. 2 Includes “Overmedication,” “Seeking Detox,” and “Other.” SOURCE: DAWN Live!, OAS, SAMHSA, updated 11/17– 11/20, 2006

Mortality Data on Benzodiazepines
Eight CEWG representatives reported on deaths with the presence of benzodiazepines (or alprazolam or diazepam) in their local and/or State areas. The Honolulu medical examiner did not report any benzodiazepinerelated deaths in the first half of 2006. Among the other seven areas, Arizona reported 2004 mortality data. The Georgia
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NFLIS Data on Benzodiazepines
Three benzodiazepine-type drugs were the most frequently reported by forensic labs in FY 2006––alprazolam, diazepam, and

Proceedings of the Community Epidemiology Work Group, January 2007

Drug Abuse Patterns and Trends Across CEWG Areas: Benzodiazepines

clonazepam. The numbers are presented for each of these drugs by CEWG area in exhibit 23.
Exhibit 23. Number of Selected Benzodiazepine Items Reported by Forensic Labs in 21 CEWG Areas: FY 2006
CEWG Area Atlanta Baltimore Boston Chicago Cincinnati Denver Detroit Ft. Lauderdale Honolulu Los Angeles Miami Mpls./St. Paul New York City Philadelphia Phoenix St. Louis San Diego San Francisco Seattle Wash., DC Texas
1

Alprazolam (Xanax) 424 255 57 63 95 24 – 574 16 120 295 17 759 910 11 32 72 19 8 41 2,432

Diazepam (Valium) 54 43 15 25 90 23 – NR1 7 116 10 23 77 86 21 20 100 44 17 15 341

Clonazepam (Clonopin, Rivotril) 58 188 61 20 62 19 – 26 3 82 15 24 155 151 18 6 73 83 13 30 466

Alprazolam. In FY 2006, alprazolam items were reported from all CEWG areas except Detroit. Alprazolam items accounted for 6.5 percent of the total drug items in Ft. Lauderdale, 3.3 percent of all drug items in Philadelphia, 2.5 percent in Atlanta, and for 1.6 percent of the drug items in both Miami and New York City. Alprazolam items represented 4.4 percent of the top 25 drug items analyzed across Texas sites. In the other 15 CEWG areas, alprazolam accounted for less than 1 percent of the drug items reported. Clonazepam. In FY 2006, clonazepam items were analyzed by forensic laboratories in 19 CEWG areas, including Texas. In all these areas, clonazepam items represented less than 1 percent of the total drug items. Diazepam. Diazepam items were reported across 18 metropolitan CEWG areas and Texas in FY 2006. In all 19 areas, diazepam items accounted for less than 1 percent of the total drug items.

NR=Not reported. SOURCE: NFLIS, DEA

Proceedings of the Community Epidemiology Work Group, January 2007

67

EPIDEMIOLOGIC TRENDS IN DRUG ABUSE: HIGHLIGHTS AND EXECUTIVE SUMMARY

Trends in Drug Use and Overdose Death in Albuquerque and New Mexico
Nina Shah, M.S., Dan Green, M.S., and Brian Woods, B.S. ABSTRACT Heroin is the most significant drug threat in New Mexico in terms of abuse. In 2005, heroin caused the most unintentional overdose deaths, followed by prescription opioids, cocaine, and drug/alcohol combinations. Heroin, cocaine, and methamphetamine overdose deaths increased roughly 40, 20, and 50 percent, respectively, from 2004 to 2005. The heroin and cocaine overdose death rates are highest among Hispanics in New Mexico, yet prescription opioid overdose deaths have sharply increased among Whites (non-Hispanic) in the past few years. Consequently, racial disparity for total drug overdose deaths is diminishing. Compared with the rest of the State, decedents residing in Albuquerque (Bernalillo County) were more likely to die from heroin (rate ratio [RR]=2.5), cocaine (RR=2.2), methadone (RR=2.6), and drug/alcohol combination overdose (RR=2.2) during 2003–2005. The burden from methamphetamine abuse is highest in the southeast and northwest regions of the State, according to indicator data from the medical examiner, HIDTA arrests, NFLIS analyses, and children in protective custody because of methamphetamine exposure; resources to combat methamphetamine abuse are targeted to these localized areas and Albuquerque. The number of methamphetamine lab incidents appears to be declining, and most methamphetamine seized in 2006 was produced in Mexico. This Mexican methamphetamine is highly pure and inexpensive. Law enforcement intelligence suggests that drug traffickers make use of the vast geography of New Mexico tribal lands for transit and refuge. Items collected and analyzed by Albuquerque forensic labs were largely cocaine (37 percent) and marijuana (34 percent). Since heroin-using networks are often familial and relatively immobile, rates of HIV infection remain low among IDUs. From January 2004 through March 2005, treatment for heroin abuse accounted for one-fifth (20.1 percent) of the 1,539 admissions for illicit drugs (excluding alcohol) in Albuquerque, while cocaine abuse accounted for 15.3 percent. (Note, however, that a large proportion of admissions was missing data for the primary drug of abuse: 37.2 percent, n=573.) Of patients admitted because of heroin abuse, 24.5 percent were White (nonHispanic) and 59.3 percent were Hispanic; in contrast, 54.5 percent of patients admitted for methamphetamine abuse were White and 32.4 percent were Hispanic. Males were treated more often for heroin abuse than females (22.7 vs. 17.4 percent), though females were treated more often than males for abuse of cocaine/crack (17.3 vs. 13.3 percent) and methamphetamine (11.6 vs.7.4 percent). The preferred route of administration for heroin was injection (89 percent), while 65 percent of patients treated for cocaine/crack abuse preferred smoking. There was an increasing trend in the proportion of methamphetamine patients who reported smoking the drug (from 18 percent in 2001 to 47 percent during January 2004–March 2005). Marijuana is the most widely available and commonly used illicit drug in New Mexico, especially among teenagers. Data from the 2005 New Mexico Youth Risk and Resiliency Survey showed that high school students in the Albuquerque area compared with students nationally were considerably more likely to report use of marijuana (30.5 vs. 20.2 percent) and cocaine (9.4 vs.3.4 percent) in the past month, as well as ever injecting an illicit drug (5.5 vs. 2.1 percent). Four percent of the Albuquerque area students reported current (past-month) heroin use; 5.7 percent reported current methamphetamine use; and 8.0 percent reported inhalant use in the month prior to survey. Drug use prevalence among the Albuquerque area students was similar to high school students in New Mexico overall.

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Proceedings of the Community Epidemiology Work Group, January 2007

Drug Abuse Patterns and Trends Across CEWG Areas: Area Abstracts

Patterns and Trends of Drug Use in Atlanta
Brian Dew, Ph.D. ABSTRACT Cocaine, marijuana, methamphetamine, and heroin are the dominant drugs of abuse in the metropolitan Atlanta area. Cocaine remains Atlanta’s primary drug concern. Cocaine was the most mentioned drug among treatment admissions, drug abuse deaths, and NFLIS drug seizure data. However, the proportion of cocaine-related treatment admissions continued a 6-year decline (from 59 percent in 2000 to 34.2 percent in the first half of 2006). Atlanta’s cocaine users were most likely to be African-American, male, and older than 35. Nearly 8 out of 10 of all cocaine users who entered treatment preferred to smoke the drug. Marijuana remains the most commonly used substance in Atlanta. Ethnographic reports suggest that marijuana is easily available, and price levels for the drug have remained stable. Indicators are mixed with regard to methamphetamine. For the first time in more than 10 years, methamphetamine-related treatment admissions decreased––from 11.4 percent in 2005 to 7.7 percent in the first half of 2006. Methamphetamine-related NFLIS drug seizure data for FY 2006 remained stable, while local law enforcement officials indicated increased use of methamphetamine in suburban Atlanta. The increased availability of and reduced cost for crystal methamphetamine led to an 11-percent increase (from FY 2005 to the first half of 2006) in treatment admissions who preferred to smoke the drug. The proportion of female to male methamphetamine users seeking treatment widened in the past 6 months, both in metropolitan Atlanta and in rural areas of the State. Although White users most frequently used methamphetamine, indicators suggest a growing level of methamphetamine use occurred among African-Americans. Heroin indicators continued to show decreasing levels of use, with the majority of users concentrated in Atlanta’s Bluff district. Rates of injecting South American heroin remained stable, although reports indicated a decrease in purity levels and an increase in price. Prescription benzodiazepines are second only to cocaine in the number of substance-related deaths across Georgia. Excluding alcohol, narcotic analgesics accounted for nearly one-half of drug-related deaths in FY 2006. Multiple indicators show that hydrocodone is the most commonly abused narcotic analgesic in Atlanta, followed by oxycodone.

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69

EPIDEMIOLOGIC TRENDS IN DRUG ABUSE: HIGHLIGHTS AND EXECUTIVE SUMMARY

Drug Use in the Baltimore Metropolitan Area: Epidemiology and Trends, 2002–2006 (First Half)
Leigh A. Henderson, Ph.D., and Doren H. Walker, M.S. ABSTRACT Heroin remained the most significant substance of abuse among drug-related treatment admissions in Baltimore in the first half of 2006 and was responsible for 47 percent of admissions. Heroin use in the Baltimore metropolitan area is complex. There were several groups of heroin users differing by urbanicity, route of administration, age, and race. Baltimore had a core of older African-American heroin users in the first half of 2006, both intranasal users and injectors (39 and 21 percent of all heroin treatment admissions, respectively; median ages 40 and 44, respectively). As a group, White users entering treatment for heroin abuse in the first half of 2006 were younger than AfricanAmerican users and were predominantly injectors rather than intranasal users (27 and 9 percent of all heroin treatment admissions, respectively; median ages 29 and 32, respectively). The cocaine situation is complicated by the fact that for every treatment admission reporting primary cocaine use, 2.4 reported secondary use. In the first half of 2006, primary cocaine use was reported by 15 percent of treatment admissions; secondary cocaine use was reported by 35 percent. Cocaine smoking was the most prevalent route of administration among both primary and secondary users. Cocaine smoking and intranasal use were associated with intranasal heroin use in 34 percent of those who smoked cocaine or used it intranasally. Cocaine injection was associated with heroin injection in 89 percent of all admissions who injected cocaine. Cocaine users younger than age 35 tended to be White, while those older than 35 tended to be African-American. Marijuana was reported more frequently as a secondary substance by treatment admissions in the first half of 2006 (19 percent) than as a primary substance (15 percent). More than one-half (57 percent) of the primary marijuana admissions reported the use of other substances, primarily alcohol (48 percent), although 10 percent reported cocaine. Some 38 percent were younger than 18, and 81 percent were male. Criminal justice referrals continued to constitute the majority of marijuana treatment admissions—65 percent in the first half of 2006. Opiates and narcotics other than heroin continued to increase as primary substances among treatment admissions. In the first half of 2006, treatment admissions for primary opiate use were 83 percent White; slightly more than one-half were male; these admissions had a median age of 35; and they reported a wide range of secondary substances. Tranquilizer use secondary to primary opiate use was reported by 14 percent of primary opiate treatment admissions. Similar numbers of treatment admissions reported primary and secondary opiate use. Secondary users were demographically similar to primary users—81 percent White and 55 percent male. Most reported opiate abuse secondary to heroin injection (33 percent) or intranasal heroin use (21 percent). Stimulants other than cocaine were rarely mentioned as the primary substance of abuse by treatment admissions.

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Proceedings of the Community Epidemiology Work Group, January 2007

Drug Abuse Patterns and Trends Across CEWG Areas: Area Abstracts

Greater Boston Patterns and Trends in Drug Abuse—January 2007
Daniel P. Dooley ABSTRACT Cocaine indicators for Boston are stable at high levels. Twenty-six percent of all treatment admissions indicated past-month cocaine use. The number of treatment admissions with past-month cocaine (including crack) use did not change from FY 2005 to FY 2006. Similarly, the number of cocaine calls to the Helpline remained stable from 2005 to 2006. Though the number of cocaine drug arrests (Class B) and drug lab samples increased, the proportion of cocaine drug arrests and drug lab samples remained stable from 2004 to 2005. Heroin abuse remains stable at very high levels in Boston. Onehalf of all treatment admissions identified heroin as the client’s primary drug. The proportion of heroin treatment admissions did not change from FY 2005 to FY 2006. The proportion of heroin calls to the substance abuse Helpline did not change from 2005 to 2006. Though levels of heroin drug arrests (Class A) and drug lab samples decreased from 2004 to 2005, analysis of data for the first half of 2006 suggests that these levels may have stabilized. Street-level heroin purchases by the Domestic Monitor Program (DEA) reveal stable price and purity from 2004 to 2005. The 2005 purchase prices averaged $0.88 per milligram pure, with an average purity level of 28 percent. Indicators for other opiates are mixed at historically high levels. The number and proportion of other opiate treatment admissions increased from FY 2005 to FY 2006. Helpline calls for opiates decreased slightly in 2006. The number of oxycodone drug lab samples increased from 2004 to 2005, but the estimate for 2006 based on data for the first half of the year is similar to 2004 and previous years. The methamphetamine abuse level remains very small according to available indicators. Accounting for less than 1 percent of all treatment admissions, the number of primary admissions for methamphetamine decreased from 75 in FY 2005 to 31 in FY 2006. Methamphetamine drug lab samples increased from 17 in 2004 to 55 in 2005 and appear stable through the first half of 2006. Recent marijuana indicators are mixed. Treatment admissions for marijuana have steadily decreased in number and as a proportion of all admissions during the past 7 years. The number of marijuana Helpline calls was unchanged from 2005 to 2006. Marijuana drug arrests (Class D) and lab samples increased in 2005. Benzodiazepine misuse and abuse levels remain fairly stable at relatively high levels. In 2005, there were 254 adult HIV/AIDS cases diagnosed in Boston. Primary transmission risk factor of these cases included 10 percent who were IDUs, 2 percent who had sex with IDUs, and 31 percent with an unknown/ undetermined risk factor.

Proceedings of the Community Epidemiology Work Group, January 2007

71

EPIDEMIOLOGIC TRENDS IN DRUG ABUSE: HIGHLIGHTS AND EXECUTIVE SUMMARY

Patterns and Trends of Drug Abuse in Chicago
Lawrence Ouellet, Ph.D., Dita Broz, M.P.H., and Wayne Wiebel, Ph.D. ABSTRACT Recent increases in deaths related to fentanyl-laced heroin highlight a growing opiate abuse problem in the Chicago area. Between May 2005 and December 2006, the Cook County Medical Examiner reported 313 deaths linked to fentanyl, with the highest numbers reported in May and June 2006 (47 deaths in each month). The Chicago division of the ISP forensic laboratory reported a significant increase in the number of drug samples positive for fentanyl during the same period. In 2006, the ISP identified fentanyl in 1,330 drug samples from metropolitan Chicago, compared with 22 samples in 2005, 3 in 2004, and 1 in 2003. Heroin is the major opiate abused in this region, and many heroin use indicators have been increasing or at already elevated levels since the mid-1990s. Drug treatment services for heroin use, which surpassed those for cocaine in FY 2001, have since nearly doubled to 33,662 episodes in FY 2005. According to preliminary unweighted data from DAWN Live!, heroin was the second most commonly reported illicit substance in emergency departments during the first 6 months of 2006. DMP data indicate heroin purity decreased in Chicago between 2000 and 2005. Availability of a high potency opiate, such as fentanyl, may be appealing to some heroin users. Epidemiological indicators continue to show that cocaine and marijuana are among the most commonly used illicit substances in Chicago. Cocaine was the second most frequently reported reason for entering publicly funded treatment programs in FY 2005, and this trend was stable over the prior 5 years. Reported marijuana-related treatment services continued to increase in Chicago, though less rapidly than in the rest of the State. According to preliminary unweighted data from DAWN Live!, cocaine and marijuana were among the top three illicit drugs most often reported in emergency departments during the first 6 months of 2006. Cocaine and marijuana, followed by heroin, were the substances most frequently seized by law enforcement in FY 2006; together, the three accounted for 978 percent of all items seized. Most MDMA indicators were stable at low levels; however, ethnographic and survey reports suggest an increased trend in use among young African-Americans. Methamphetamine indicators continued to show low but perhaps increasing levels of use in some areas of Chicago, especially on the north side, where young gay men and clubgoers congregate.

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Proceedings of the Community Epidemiology Work Group, January 2007

Drug Abuse Patterns and Trends Across CEWG Areas: Area Abstracts

Drug Abuse Patterns and Trends in Cincinnati (Hamilton County)
Jan Scaglione, B.S., M.T. PharmD, DABAT ABSTRACT The reader should be aware of the following: in October 2006, the Alcohol and Drug Addiction Services Board merged with the Mental Health and Recovery Services Board in Hamilton County, Ohio. After the merger, treatment data for FY 2006 could not be located. Recovered treatment data presented here are estimated to represent between 65 and 75 percent of the total treatment services provided during FY 2006. The recovered data are expected to closely reflect the overall percentage of total treatment services provided to residents of Hamilton County. Drug abuse indicators continue to show cocaine/crack cocaine at high levels throughout Cincinnati. Twenty-six percent of the known public treatment admissions for FY 2006 included primary cocaine use. Cocaine submissions recorded by the National Forensic Laboratory Information System (NFLIS) accounted for 48 percent of the total items reported, and cocaine represented 36 percent of those drug items recorded by the Hamilton County Coroner’s Office Laboratory. The average purity of cocaine items submitted to the Drug Enforcement Administration (DEA) laboratory for analysis was 80 percent. Hamilton County law enforcement seizures of powder cocaine for the first 11 months of 2006 were twice that of the first 11 months of the previous year. Cocaine was detected in 49 decedents, ranking it second only to alcoholrelated deaths during the first 6 months of 2006. Intentional exposure cases in which cocaine was recorded as an involved substance in poison control center data doubled from 2005 through 2006. Marijuana indicators also remained at a high level, accounting for 19 percent of all treatment admissions (27 percent excluding alcohol) during FY 2006. Marijuana submissions reported to NFLIS accounted for 39 percent of the total submissions, and 46 percent of drug items submitted to the Hamilton County Coroner Laboratory were marijuana. Indicators for heroin use showed the drug accounted for nearly 17 percent of publicly funded treatment admissions for illicit drugs and for 4–5 percent of law enforcement drug seizures. Methamphetamine abuse stabilized across the State of Ohio, accounting for very few treatment admissions. Prescription opioids and benzodiazepines remained a problem across the area. Epidemiologic indicators for MDMA indicated limited use across the Cincinnati region during 2006.

Proceedings of the Community Epidemiology Work Group, January 2007

73

EPIDEMIOLOGIC TRENDS IN DRUG ABUSE: HIGHLIGHTS AND EXECUTIVE SUMMARY

Patterns and Trends in Drug Abuse in Denver and Colorado: January–June 2006
Tamara Hoxworth, Ph.D. ABSTRACT Excluding alcohol, marijuana abuse has continued to result in the highest number of treatment admissions annually since 1997; marijuana treatment admissions have remained fairly stable over the last 3 years. In the first half of 2006, cocaine ranked third in treatment admissions, but the drug accounted for the highest illicit drug rate per 100,000 persons for hospital discharges from 1996 through 2005 and for the highest number of illicit unweighted drug ED reports in the first half of 2006. Cocaine also accounted for the highest drug-related mortality rates from 1996 through 2002; it was surpassed in 2003 by all opiates including heroin and in 2004 and 2005 by opiates other than heroin. Cocaine had the highest number of illicit drug-related calls to the Rocky Mountain Poison & Drug Center from 2001 through 2003 in the Denver area, but was surpassed by methamphetamine in 2004 and 2005. However, in the first half of 2006, there were significantly more poison calls for cocaine than for methamphetamine (67 vs. 17, respectively). Methamphetamine has exceeded cocaine in statewide treatment admissions statewide since 2003, and in Denver/Boulder treatment admissions since 2005. However, the first decline in several years for methamphetamine admissions and poison calls occurred in the first half of 2006. Clandestine laboratory closures have decreased steadily since 2003, but the amount of methamphetamine seized increased through 2005, most likely because an estimated 80 percent of Colorado's methamphetamine comes from outside the State, predominantly Mexico. Moreover, drug enforcement officials have reported increased purity levels of methamphetamine seized in Colorado. Many heroin abuse indicators decreased over the last several years, while poison calls remained stable. In 2003 through 2005, opiate-related drug misuse mortalities exceeded those that were cocaine related. Beyond abuse of illicit drugs, alcohol remained Colorado’s most frequently abused substance and accounted for the most treatment admissions, unweighted emergency department reports, poison center calls, drug-related hospital discharges, and drug-related mortality.

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Proceedings of the Community Epidemiology Work Group, January 2007

Drug Abuse Patterns and Trends Across CEWG Areas: Area Abstracts

Drug Abuse in Detroit, Wayne County, and Michigan
Cynthia L. Arfken, Ph.D. ABSTRACT Cocaine and heroin are the two major drugs of abuse in the area, but marijuana is the most widespread. Cocaine treatment admissions increased from FY 2005 to FY 2006, when they accounted for 41 percent of primary illicit drug admissions (excluding alcohol); 95 percent of these admissions were for crack cocaine. Of the cocaine/crack admissions, 59 percent were male, 93 percent were African-American, and 85 percent were older than 35. Cocaine accounted for 51 percent of the unweighted ED illicit drug reports (excluding alcohol) in the first half of 2006 and for 46 percent of the drug items reported by NFLIS in FY 2006. From January through September 2006, the medical examiner (ME) reported 320 deaths involving cocaine, the highest number for all drugs reported in that time period. In FY 2006, heroin treatment admissions declined to represent 38 percent of the primary illicit drug admissions; 59 percent were male, 90 percent were African-American, and 93 percent were older than 35. Heroin accounted for 25 percent of the illicit drug ED reports in the first half of 2005, and 185 deaths involving heroin were reported by the ME in the first 9 months of 2006. The number of heroin items reviewed by forensic laboratories increased; 21 percent of the items analyzed in FY 2006 contained heroin. This increase may be related to fentanyl surveillance; it also followed an increase in heroin purity and a drop in price in 2005, as documented by the Domestic Monitor Program. Opiates other than heroin accounted for 1.6 percent of primary illicit drug admissions in FY 2006. In the unweighted DAWN Live! data for the first half of 2006, there were 1,348 opiates/opioids reports for the metropolitan area; 27.0 percent were hydrocodone reports, 11.7 percent were methadone reports, 8.6 percent were oxycodone reports, and 4.5 percent were fentanyl reports (the remainder were ‘unspecified’). In the first 9 months of 2006, the ME reported 176 deaths with the presence of fentanyl, 138 involving hydrocodone, and 77 involving methadone. The deaths involving fentanyl increased more than 272 percent from 2005. The lethal combination of heroin or cocaine and fentanyl, which appeared in Detroit and northern Michigan during the second half of 2005, continues to kill people with no sign of disappearing. Outreach efforts were implemented to disseminate information to at-risk people on the streets about this new threat, and efforts are underway to implement an overdose prevention approach to fentanyl and fentnayl mixtures. Treatment admissions for marijuana increased steadily since 2003, accounting for 19 percent of the primary illicit drug admissions in FY 2006. Of these admissions, 73 percent were male, 94 percent were African-American, and 54 percent were younger than 26. Marijuana represented one-fifth of the unweighted ED reports for illicit drugs in the first half of 2006 and 23 percent of the drug items reported by NFLIS in FY 2006. The indicators for methamphetamine remained low. Ecstasy use is still troublesome, as evidenced by treatment admissions and ME reports

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EPIDEMIOLOGIC TRENDS IN DRUG ABUSE: HIGHLIGHTS AND EXECUTIVE SUMMARY

Illicit Drug Use in Honolulu and the State of Hawaii
D. William Wood, M.P.H., Ph.D. ABSTRACT During the first half of 2006, methamphetamine continued to dominate the drug abuse scene in Honolulu and the State. While there were slight declines in some methamphetamine abuse indicators, primary methamphetamine admissions continued to account for more than 55 percent of all illicit drug admissions (excluding alcohol), and 57 percent of the drug items reported by NFLIS in FY 2006 contained methamphetamine. In the first half of 2006, the Honolulu medical examiner reported 22 deaths with the presence of methamphetamine, and the Honolulu Police Department (HPD) reported 390 arrest cases involving the drug. According to the 2007 HIDTA Threat Assessment report, law enforcement pressures related to methamphetamine increased in 2006. Asian drug trafficking organizations (DTOs) and criminal groups (including those of Cambodian, Chinese, East Indian, Filipino, Japanese, Korean, Laotian, Thai, and Vietnamese descent) transport and distribute wholesale quantities of ice and power methamphetamine (as well as marijuana, MDMA, and other drugs). In 2005, 12 percent of the methamphetamine samples studied tested positive for Asian manufacture. However, the majority of crystal methamphetamine (and cocaine and heroin) is still supplied from the U.S. west coast and Mexican DTOs. Marijuana abuse indicators remained stable and at high levels. Treatment admissions for primary marijuana abuse were relatively stable, at 29 percent of all illicit admissions in the first half of 2006. Approximately 20 percent of the items tested by forensic labs in FY 2006 were positive for marijuana. Seizures of marijuana plants decreased 29 percent from 6,814 in the second half of 2005 to 4,786 in the first half of 2006; however, the weight of the seizures increased from 81,966 grams in the first half of 2005 to 88,244 grams in the first half of 2006. Cocaine abuse indicators increased during this reporting period. There were 50 percent more decedents with positive cocaine toxicology screens, 50 percent more cocaine arrest cases reported by the HPD, and a 10percent increase in primary cocaine admissions. Cocaine accounted for approximately 16 percent of the items reported by NFLIS in FY 2006. Heroin abuse indicators remained relatively low and stable. Heroin accounted for less than 4 percent of all illicit treatment admissions and for less than 2 percent of the NFLIS items. Three decedents were positive for heroin, and there were six heroin arrest cases in the first half of 2006. However, in the first half of 2006, there was an increase in positive decedent presence of opiates other than heroin (10 involving methadone and 12 involving other opiates in the first half of 2006).

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Drug Abuse Patterns and Trends Across CEWG Areas: Area Abstracts

Patterns and Trends in Drug Abuse in Los Angeles County, California: A Semi-Annual Update
Alison Hamilton, Ph.D. and Beth Rutkowski, M.P.H. ABSTRACT Along with the rest of California, Los Angeles treatment data are unavailable at this time because of a shift to a new data management system. Cocaine and methamphetamine together accounted for 66 percent of all Los Angeles-based illicit drug items analyzed and recorded by the NFLIS from October 2005 through September 2006; analgesics and benzodiazepines accounted for 71 percent of pharmaceutical/non-controlled drug items. Drug prices and purities were relatively stable from 2005 through the first half of 2006. Los Angeles was just above (8.2 percent) the national average (8.1 percent) of past-month illicit drug use, according to a recent National Survey on Drug Use and Health report about substance use in the 15 largest metropolitan statistical areas. The rates of past-month binge drinking and cigarette use were both lower in Los Angeles than the national average. Weighted adolescent substance use data collected in the Youth Behavior Risk Surveillance Survey (2005) illustrated that past-month usage percentages among Los Angeles County secondary school students decreased or remained stable between the survey periods of 2001, 2003, and 2005, and the number of those initiating drug behavior before age 13 decreased (for alcohol and cigarettes) or remained stable (for marijuana). In the 2005 survey, approximately 40.0 percent of females and males reported lifetime use of marijuana, followed by inhalant use for 14.5 percent of males and 21.5 percent of females. More females (13.2 percent) than males (6.9 percent) reported lifetime cocaine use, and slightly more females (10.9 percent) than males (9.5 percent) reported lifetime methamphetamine use. Mexican black tar heroin continues to be the heroin of choice in Los Angeles, though there has been a 0.3 percentage point decline in average purity and a $0.10 increase in price per milligram pure. Heroin-related deaths appear to have increased by approximately 75 percent from 2002 to 2005, and this jump in deaths was most prevalent among users older than 40. Both indoor and outdoor production of marijuana in California far exceeds production in any other State, with California producing 8,622,831 pounds, and the next highest producing State, Tennessee, producing 2,980,853 pounds. Methamphetamine continues to dominate the treatment system. Findings from the Los Angeles County Evaluation System indicate that participants in this evaluation admitted for primary methamphetamine use increased from 19.0 percent in 2001 to 36.4 percent in 2005. Females were more likely to report primary methamphetamine use than males over the entire 5 years of the evaluation, and the proportion of 18–25-year-olds reporting primary methamphetamine use increased from 31.3 percent to 52.8 percent. The percentage of Asians, Latinos, Native Americans, and Whites entering county-funded treatment for primary methamphetamine use increased from 29.3 percent in 2001 to 49.0 percent in 2005. However, during this period, only 3.3 percent of African-American participants entered treatment for primary methamphetamine use. The Los Angeles HIDTA region (comprised of Los Angeles, Orange, Riverside, and San Bernardino Counties) accounted for 31 percent of the 227 clandestine methamphetamine laboratory incidents in California in the first half of 2006. California had the 5th highest number of laboratory seizures in the United States in the first half of 2006 and remains the home of the domestic methamphetamine ‘superlab.’ Eighty-six percent of the 14 superlabs seized throughout the United States from January to June 2006 were located in California; of those, 25 percent were located in LA HIDTA counties. There is growing concern about the abuse of dextromethorphan among adolescents, according to a recent study of poison control exposure cases in California. There were dramatic increases in the sales of methadone, fentanyl, and Adderall to hospitals and pharmacies in Los Angeles County between 2001 and 2005. Regarding AIDS cases diagnosed in 2005 in Los Angeles County, 62 percent of males were infected through sexual contact with another male, and 6 percent were infected through sexual contact with an intravenous drug user. Forty percent of females were infected through heterosexual contact, and 17 percent were infected through sexual contact with an IDU.

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EPIDEMIOLOGIC TRENDS IN DRUG ABUSE: HIGHLIGHTS AND EXECUTIVE SUMMARY

Maine Trends and Drug Abuse Patterns: January 2007
Marcella H. Sorg, RN, Ph.D., D-ABFA ABSTRACT Overall, Maine continues to experience serious problems with prescription drugs, primarily narcotics. Methadone exceeds all other narcotics in mortality. Trafficking in pharmaceuticals across the U.S.Canadian border is significant. The proportion of cocaine and methamphetamine arrests rose in 2006, although the number of labs seized was stable. Buprenorphine diversion is now reported ethnographically and was the reason for 15 percent of narcotics-related poison control exposure/abuse calls in the first three quarters of 2006. Cocaine indicators for Maine are mixed. Use in the past 30 days reported by Maine youth in grades 6–12 in 2006 was stable or had slightly decreased for students in most grades compared with that reported 2004. Eight percent of Maine 12th graders reported any lifetime use in 2006. Fourteen percent of 2006 drug treatment admissions, excluding alcohol, involved a primary problem with cocaine/crack; the proportion and number have risen steadily each year since 2000. The proportion of cocaine/crack arrests by the Maine Drug Enforcement Agency (MDEA) rose from 39 percent in 2005 to 44 percent 2006. Most arrests involved powder cocaine; however, crack arrests rose from 2005 to 2006, while powder arrests declined. Cocaine-induced deaths were level from 2004 to 2005, and 2006 projected totals appear stable. Poison control cocaine abuse/exposure calls decreased 25 percent from 2004 to 2005, and 2006 projections show a further decrease. Heroin indicators are stable or decreasing. Heroin use reported by Maine youth decreased slightly between 2004 and 2006. Primary heroin/morphine admissions were relatively stable from 2005 to 2006; however, new admissions dropped 20 percent. Heroin/morphine-induced deaths doubled from 2004 to 2005, but the increase appears to be related to pharmaceutical morphine; the projected 2006 total appears level with 2005. Poison control heroin abuse/exposure calls, level from 2003 to 2005, dropped during the first 3 quarters of 2006. Heroin arrests by the MDEA were also stable from 2004 to 2005 but dropped sharply from 13 percent in 2005 to 3 percent in 2006. NDIC reports 2006 Maine heroin prices at $250–$350 per gram in Portland and $75–$100 per gram further north in Lewiston. Pharmaceutical narcotics continue to play a primary role in drug misuse/abuse and trafficking in Maine. Students in grades 6–12 reported less misuse of pharmaceuticals in 2006, down slightly from 2004. However, primary pharmaceutical narcotic treatment admissions in 2006 increased 9 percent over 2005 and constituted 42 percent of 2006 drug admissions; 14 percent of these were first admissions. Oxycodone primary admissions dominated the 2006 narcotic distribution at 31 percent of all drug admissions in 2006; additionally, 41 percent of heroin admissions report oxycodone as a secondary or tertiary problem. Methadone has caused more deaths than any other drug (38 percent of the 2005 drug deaths), with the majority involving tablets; the rate appears to have stabilized in 2006 projections. Similarly, poison control calls involving abuse/exposure to methadone constituted the largest proportion of all 2005 narcotics-related calls (26 percent), followed closely by hydrocodone and oxycodone (both 20 percent). Maine’s prescription monitoring program, used to identify and deter prescription drug diversion and misuse, reports that hydrocodone/acetaminophen is the most commonly identified controlled substance prescription (21 percent), followed by oxycodone preparations (11 percent) and lorazepam (8 percent). The proportion of MDEA arrests involving prescription drugs was 27 percent in 2005 and 25 percent in 2006, second only to crack/cocaine. Methamphetamine indicators are low but continue to rise. MDEA arrests increased sharply from 1 percent in 2005 to 7 percent in 2006. Lab seizures stayed level during Maine’s first full year with overthe-counter pseudoephedrine controls. Poison control abuse/exposure calls involving methamphetamine are low, but they nearly tripled between 2005 and 2006. Primary admissions for methamphetamine abuse remained low and stable from 2005 to 2006, at 0.9 percent. Marijuana indicators are down. Maine youth reported less marijuana use in 2006 than previously. Primary admissions for marijuana abuse dropped from 26 percent in 2005 to 22 percent in 2006. The proportion of MDEA arrests for marijuana increased slightly from 17 percent in 2005 to 20 percent in 2006, but they decreased in number.

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Drug Abuse Patterns and Trends Across CEWG Areas: Area Abstracts

Drug Abuse in Miami/Ft. Lauderdale, Florida: January–June 2006
James N. Hall ABSTRACT Drug-related deaths declined across Florida in the first half of 2006 compared with the previous 6 months for prescription medications and most illicit drugs. The exceptions were methamphetamine and MDMA; drug-related deaths for these substances increased. Miami-Dade County reported fewer deaths from all illicit drugs and medications in the first 6 months of 2006 compared with 2005. In Broward County, only heroin-related deaths increased. Cocaine was responsible for the highest number of drug consequences in Miami-Dade County. Deaths related to the nonmedical use of prescription drugs dominated fatalities in Broward County. While the population of Miami-Dade County exceeds that of Broward County by 1 million people, the numbers of deaths, emergency department reports, and crime lab items related to the nonmedical use of prescription drugs in Broward County were more than double the numbers for Miami-Dade County. Methadone leads all other opiates in drug-related deaths locally and statewide, followed by oxycodone, which is the most frequently mentioned opiate for all other indicators. Alprazolam (Xanax) is the most frequently cited benzodiazepine related to nonmedical use. Marijuana ranks second after cocaine (excluding alcohol) in unweighted emergency department reports, treatment admissions, and crime lab items. Measures of MDMA (‘ecstasy’) consequences and use increased slightly in the first half of 2006, reversing declining trends since 2001. GHB problems were reported at very low levels and continue to decline. Indicators of methamphetamine abuse also remain low, yet criminal cases are rising as high potency ‘Mexican Ice’ is being trafficked via Atlanta into Florida. Sexual activity related to methamphetamine abuse is cited by public health officials as the key factor for why Miami-Dade and Broward Counties rank first and second in the Nation in per capita rates of HIV infection. Statewide trends from the Florida Youth Survey on Substance Abuse reflect overall declines in use for all substances of abuse among middle and high school students from 2000 to 2006 but increases between 2005 and 2006.

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EPIDEMIOLOGIC TRENDS IN DRUG ABUSE: HIGHLIGHTS AND EXECUTIVE SUMMARY

Drug Abuse Trends in Minneapolis/St. Paul, Minnesota
Carol Falkowski ABSTRACT Numerous indicators of methamphetamine abuse declined in 2006, reversing previous upward trends. Collectively, these new findings demonstrate that the growth in methamphetamine abuse is slowing down, possibly reversing itself in the Twin Cities area. The number of clandestine methamphetamine labs declined statewide to 59 in 2006 (through November), compared with 112 in 2005 (full year) and 212 in 2004. Admissions to addiction treatment programs for methamphetamine also declined in 2006; they fell 37 percent from the last half of 2005 to the first half of 2006. There were 806 in 2006 (first half) (representing 8.2 percent of total treatment admissions), compared with 2,465 in 2005 (representing 12.0 percent of total treatment admissions that year). In 2006 (first half), 4.5 percent of methamphetamine treatment admissions were patients younger than 18, compared with 11.5 percent in the first half of 2005. Unweighted methamphetamine-related hospital ED episodes in the Twin Cities totaled 251 in the first half of 2006. It remains to be seen whether these findings reflect the beginning of a decline in the actual prevalence of methamphetamine abuse, especially among the younger, adolescent population group. Alcohol remained the most widely abused drug. According to a new survey of undergraduate students at the University of Minnesota, high-risk drinking, defined as consuming five or more drinks at one sitting in the past 2 weeks, was reported by roughly 42 percent of students age 18–20. Students who reported high-risk drinking were more likely than students who did not to report more negative consequences related to alcohol use, such as elevated rates of driving while intoxicated, getting in an argument, doing poorly on a test, missing a class, and being taken advantage of sexually. High-risk drinking rates were more than two times higher among tobacco users (71.6 percent) than non-tobacco users (34 percent).

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Drug Abuse Patterns and Trends Across CEWG Areas: Area Abstracts

Drug Abuse Patterns and Trends in New York City
Rozanne Marel, Ph.D., John Galea, M.A., and Robinson B. Smith, M.A. ABSTRACT Drug use trends in New York City were again mixed for this reporting period. Cocaine indicators continue to be stable, and cocaine remains a major problem in New York City. Primary cocaine admissions constitute one-quarter of New York City’s drug and alcohol treatment admissions, and more than 56 percent of clients in treatment report cocaine as a primary, secondary, or tertiary drug. Heroin indicators were mixed for this reporting period. Heroin remains widely available. While last year there was a substantial decrease in purity and an increase in price, that trend has reversed. The purity level (49.4 percent), however, is still lower than the 60.0 percent levels that had been noted for several years. Almost all heroin in New York City is from South America, although there have been law enforcement reports of Mexican black tar heroin being seized in New York. Marijuana indicators, which had been reaching new peaks, seem to have stabilized. Marijuana continues to be of good quality and available in a wide variety of flavors and colors. Many users mix and combine drugs for simultaneous use. Although the numbers remain small, methamphetamine indicators are showing an increase in the gay community, as well as the nightclub population of New York City. Street sources report that the methamphetamine in New York City is low in quality and high in price. Many kinds of prescription drugs are increasingly popular and available on the street. Of the 96,829 New Yorkers living with HIV or AIDS, men having sex with men and injection drug use history continue to be the 2 major transmission risk factors. While the number and proportion of new HIV diagnoses attributed to injection drug use continue to decline, IDUs are more likely than other transmission categories to delay initiation of care and to die from HIV-related causes.

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EPIDEMIOLOGIC TRENDS IN DRUG ABUSE: HIGHLIGHTS AND EXECUTIVE SUMMARY

Drug Use in Philadelphia, Pennsylvania
Samuel J. Cutler and Marvin F. Levine, M.S.W. ABSTRACT Indicators remained mostly stable for the four major drugs of abuse—cocaine, heroin, marijuana, and alcohol. However, numerous other drugs are used that contribute to the abuse patterns in this city. Cocaine abuse, particularly in the form of crack, continued to lead the consequence data in the first half of 2006 with respect to deaths with the presence of drugs, treatment admissions, and laboratory tests performed by NFLIS. It was the second substance most frequently encountered in urine/drug screens performed by the Philadelphia Adult Probation and Parole Department (APPD). The streetlevel purity of heroin declined from 2000 (73 percent) through the spring of 2006 (38 percent), which appears to have caused users to seek or approximate a high through the use of increased amounts or adding other drugs to use in combination. In the first half of 2006, heroin ranked fourth among deaths with the presence of drugs and treatment admissions, third in the NFLIS, and fourth in APPD urinalysis. Deaths with the presence of oxycodone ranked seventh among all positive toxicology reports in the first half of 2006. Marijuana, which is not tested for in decedents, was the most frequently detected drug by the APPD, ranked second in the NFLIS study, and was third in treatment admissions. Alcohol in combination with other drugs ranked third in drugs detected in decedents and second in treatment admissions. Alcohol ranked seventh in APPD urinalysis results. The two most frequently abused benzodiazepines continued to be alprazolam and diazepam, although others are abused/misused. As a group, benzodiazepines were the second most frequently detected drugs in decedents in the first half of 2006 and ranked fourth in the NFLIS study. Benzodiazepines ranked sixth among drugs of abuse mentioned by clients in treatment. Methamphetamine indicators continued to be low compared with other drugs. The drug’s use is largely confined to a relatively small segment of the population. The average number of drugs detected in decedents leveled off in 2005 but increased in the first half of 2006. The average increased from 1.97 per decedent in 1995 to 4.05 in the first half of 2006. Starting April 17, 2006, packets of drugs sold on the street purporting to be heroin also contained fentanyl. The authors attribute the increases in deaths and the average number of drugs per decedent to the inclusion of fentanyl in the drug packets.

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Drug Abuse Patterns and Trends Across CEWG Areas: Area Abstracts

Drug Abuse Patterns and Trends in Phoenix and Arizona
Ilene L. Dode, Ph.D. ABSTRACT Arizona has become the fastest growing State in the Nation. Non-Whites constitute 51.7 percent of the population of Phoenix. Besides being the main entry point for undocumented immigrants, Arizona is becoming the key gateway for marijuana smuggling, with 331.3 tons confiscated in FY 2006. In the first quarter of 2007, 106 tons worth $170,000,000 have been seized. The age at which most drugoverdose deaths occur has increased with the aging of the baby boomers. In 1970, the most frequent age was 22; this has progressed with each decade and, by 2004, the peak age range was the late forties. Drug-related death rates for all ages increased from 1.8 in 1985 to 5.4 in 1995 to 8.9 per 100,000 in 2004. Age-adjusted mortality rates per 100,000 population for drug-induced deaths by gender and race in 2004 differed. For males, American Indians had the highest rate of drug-related deaths (23.0 per 100,000), and for females, White non-Hispanics had the highest rate (11.1 per 100,000). Hospital discharge data continue to show that methamphetamine is the major substance of abuse in Maricopa County, while cocaine is the major substance of abuse in Tucson. Stimulants accounted for the largest proportion (34.1 percent) of the major substances of abuse (excluding alcohol) in the unweighted DAWN Live! data for the first half of 2006, with methamphetamine accounting for 25.5 percent of the reports and amphetamines for 8.7 percent. Thirty-six percent of treatment admissions in FY 2006 were for methamphetamine and other stimulants. Only alcohol admissions were greater. Needle exchange began in Pima County (Tucson) in 1996. The mean annual rate per 100,000 county population of injection drug-related annual HIV emergence pre-needle exchange in Maricopa County (Phoenix) was 6.3 per 100,000, and it was 6.4 in Pima County. The post-needle exchange mean annual rate for Maricopa County (no needle exchange) was 3.4 per 100,000, and it was 3.2 per 100,000 in Pima County.

Proceedings of the Community Epidemiology Work Group, January 2007

83

EPIDEMIOLOGIC TRENDS IN DRUG ABUSE: HIGHLIGHTS AND EXECUTIVE SUMMARY

Patterns and Trends in Drug Abuse in St. Louis
Heidi Israel, Ph.D., R.N., L.C.S.W., and James Topolski, Ph.D. ABSTRACT Recently, St. Louis has been identified as the most dangerous city in the Nation, with drug use cited as a contributing factor. Law enforcement personnel in the St. Louis area continued to devote many resources to methamphetamine, and clandestine laboratory incidents have decreased dramatically since legislation to reduce access to pseudoephedrine-based cold medications was enacted in the summer of 2005. Access to methamphetamine from Mexico and the Southwest is considered to be the major component of the methamphetamine problem in the area. Treatment admissions in the St. Louis area for methamphetamine abuse decreased 21 percent from the first half of 2005 to the first half of 2006, while statewide treatment admissions increased 4 percent over the same timeframe. The St. Louis area continues to experience a two-pronged opiate problem. A major issue was the increase in deaths related to the use of heroin and fentanyl earlier in 2006. While this issue had gained widespread media attention in the St. Louis area, more data need to be collected and analyzed to determine the extent and nature of the problem. There has been confirmation of 30 fentanyl-related deaths in the metropolitan area: 14 in the city of St. Louis and 16 in the surrounding area. Heroin activity had been increasing, but treatment admissions in the St. Louis area decreased 11 percent from the first half of 2005 to the first half of 2006 and decreased statewide over the same period by 5 percent. Reports of white heroin supplies have increased over the past years and have been supported by DEA data. The other side of the opiate problem is the abuse of narcotic analgesics. Treatment admissions for abuse of other opiates increased 19 percent from the first half of 2005 to the first half of 2006, after increasing 62 percent from 2004 to 2005 in the St. Louis area. Statewide admissions for these substances increased 28 percent over the same timeframe. Crack cocaine continued to be the major problem in the area, but most indicators have remained relatively stable. Treatment admissions were down slightly (6 percent) from the first half of 2005 to the first half of 2006 in the St. Louis area, but they were up 9 percent statewide. Marijuana indicators continue to increase, with treatment admissions increasing 11 percent in the St. Louis area and 21 percent statewide from the first half of 2005 to the first half of 2006. Anecdotal reports of the abuse of prescription medications, cough medication, and inhalants continue to be widespread.

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Drug Abuse Patterns and Trends Across CEWG Areas: Area Abstracts

Drug Abuse Patterns and Trends in San Diego County, California
Robin Pollini, Ph.D., and Steffanie Strathdee, Ph.D. ABSTRACT Methamphetamine is the primary illicit drug of abuse in San Diego County, leading all other drugs in most indicator categories. Methamphetamine was the primary drug of abuse for 49.2 percent of all drug treatment admissions (excluding alcohol) in San Diego County in 2005; the drug most commonly cited in unweighted DAWN ED reports involving major illicit drugs from January 1 to June 30, 2006 (32.1 percent); and the most prevalent illicit drug detected among male (44 percent) and female (51 percent) adult arrestees in 2005. The prevalence of methamphetamine use among male, female, and juvenile arrestees in San Diego has increased by 29 percent, 38 percent, and 75 percent, respectively, since 2002. Heroin was the primary drug of abuse for 23.8 percent of those admitted to treatment in 2005 and for 72.4 percent of primary injectors; however, heroin ranked behind methamphetamine and marijuana in unweighted DAWN ED reports in the major illicit drug category. Treatment admissions for primary use of ‘other opiates’ (e.g., hydrocodone, oxycodone) remained low at 2.2 percent, but this is the only drug category for which the overall number of treatment admissions has increased since 2002 (by 26 percent). The number of unweighted DAWN ED reports for other opiates (n=460) exceeds reports for heroin (n=371), cocaine (n=342), and marijuana (n=432). Primary treatment admissions for cocaine accounted for only 8.2 percent of treatment admissions, but there were only slightly fewer unweighted DAWN ED reports for cocaine than for heroin.

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EPIDEMIOLOGIC TRENDS IN DRUG ABUSE: HIGHLIGHTS AND EXECUTIVE SUMMARY

Patterns and Trends of Drug Use in the San Francisco Bay Area
John A. Newmeyer, Ph.D. ABSTRACT Indicators for cocaine use showed a level trend in the 2003–2006 period. Similarly, methamphetamine use indicators appear level after significant increases during the 2001–2004 period. Heroin use indicators have been consistently declining since 2000. Very little club drug use is seen. AIDS incidence has been decelerating in San Francisco for many years. However, the increase in reported AIDS cases in the year ending September 30, 2006, was more than twice as great among gay male IDUs as among the overall population (3.5 vs. 1.6 percent), indicating that the ‘speed/sex’ nexus continues to play a major role in residual HIV contagion. An NSDUH study found that San Francisco adults reported the highest recent use of illicit drugs (12.7 percent), but the lowest recent use of tobacco (17.9 percent), among 15 U.S. metropolitan areas. The likeliest explanation is that San Francisco has more older adults using illicit drugs (especially marijuana) than most U.S. cities; fully 84 percent of FY 2005 treatment admissions in San Francisco County were 26 or older. The NSDUH study also found that reported illicit drug use among nonmetropolitan areas of Northern California was even greater than that in the San Francisco Bay area; this suggests that an ‘out-migration’ of substance use patterns may have transpired.

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Drug Abuse Patterns and Trends Across CEWG Areas: Area Abstracts

Recent Drug Abuse Trends in the Seattle-King County Area
Caleb Banta-Green, T. Ron Jackson, Michael Hanrahan, Steve Freng, Susan Kingston, David H. Albert, Ann Forbes, Richard Harruff, and Sara Miller ABSTRACT
Data for the Seattle-King County region for the first half of 2006 indicate that prescription-type opiates, heroin, cocaine, and methamphetamine are the major drugs associated with morbidity and mortality. Overall, drug-caused deaths are at the highest level in at least 10 years. A total of 150 drugcaused deaths occurred in the first half of 2006—a rate of 8.4 per 100,000 population per half-year. Prescription-type opiate-involved deaths continue to increase and remain the most common drug type identified, totaling 83 in the first half of the year. Treatment admissions for prescription-type opiates continue to increase, though the overall rate remains low. A total of 1,054 (unweighted) drug abuse/‘other’ case type reports for prescription-type opiates were reported by area emergency departments, similar to the 1,001 unweighted reports for heroin for all case types. The total of 38 heroin/opiate-involved deaths is down somewhat compared with recent years. Treatment admissions for heroin are relatively stable, with approximately 1 in 5 persons reporting any heroin use at treatment entry for all ages and treatment modalities. Stimulant usage remains prevalent, with cocaine morbidity and mortality unrelenting. Approximately 45 percent of persons entering treatment report using cocaine. Both the rate and number (n=54) of cocaine-involved deaths are at the highest levels seen in at least 10 years. In emergency departments, cocaine is the most commonly identified illicit drug (n=1,255 unweighted reports). Local methamphetamine manufacturing appears to be continuing its rapid descent. Methamphetamine ED reports (unweighted) totaled 794. Deaths involving methamphetamine totaled 13, similar to recent years, while treatment admissions continued to increase, with 19 percent of people admitted to treatment reporting any methamphetamine use.

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EPIDEMIOLOGIC TRENDS IN DRUG ABUSE: HIGHLIGHTS AND EXECUTIVE SUMMARY

Substance Abuse Trends in Texas, January 2007
Jane Carlisle Maxwell, Ph.D. ABSTRACT Cocaine is the primary illicit drug for which Texans enter treatment, and it is a major problem on the border with Mexico, with increased purity levels and seizures. Indicators of cocaine use remain stable or are increasing, although methamphetamine and ice are becoming more popular than cocaine in some areas. Crack cocaine admissions are more likely to be White or Hispanic. Heroin indicators are stable or dropping; addicts entering treatment are primarily injectors. Heroin purity is increasing, and ‘Cheese,’ a mixture of Tylenol PM and 1 percent heroin, has been reported in the Dallas schools. Hydrocodone is a larger problem than oxycodone or methadone, and fentanyl indicators are low but fluctuate from year to year. Methadone indicators are increasing. Methadone users are predominately White, and more adverse events appear to be related to methadone pain pills. Codeine cough syrup, ‘Lean,’ continues to be abused. Marijuana indicators are mixed, and treatment admissions with criminal justice problems are less impaired than those who are referred from other sources. Methamphetamine is a growing problem across the State, and smoking ice is the major route of administration for persons entering treatment. Most of the ice and methamphetamine is made in Mexico, but local laboratories are using different ingredients to replace the pseudoephedrine that is becoming more limited in supply. Abuse of alprazolam (Xanax) and carisoprodol (Soma) is increasing. Indicators of ecstasy use are increasing as the drug spreads from the White club scene to a diverse racial/ethnic population. GHB and GBL remain problems, particularly in the Dallas-Fort Worth metroplex area. PCP indicators are stable or rising, and dextromethorphan is a problem among adolescents. Inhalants remain a problem, with different types of users. HIV and AIDS cases are more likely to be persons of color, and the proportions of HIV and AIDS cases related to male-to-male sex are increasing. The heterosexual mode of transmission now exceeds injection drug use.

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Drug Abuse Patterns and Trends Across CEWG Areas: Area Abstracts

Patterns and Trends of Drug Abuse in Washington, DC
Erin Artigiani, M.A.; Maribeth Rezey, B.S.; Joseph Tedeschi; Margaret Hsu, M.H.S.; and Eric Wish, Ph.D. ABSTRACT Cocaine/crack, marijuana, and heroin continued to be the main illicit drug problems in Washington, DC, in 2006. The use and availability of PCP continued to fluctuate. Cocaine remained one of the most serious drugs of abuse in the District, as evidenced by the fact that more adult arrestees tested positive for cocaine than for any other drug in 2006, and the number is increasing. In the first 11 months of 2006, approximately 40 percent of adult arrestees tested cocaine positive at the Pretrial Services Agency. Also, more seized items tested positive for cocaine (42 percent) than for any other drug, as reported by NFLIS in FY 2006. Drug-related deaths, however, were more likely to be related to opiates than to cocaine in 2004 (n=73 vs. 62). Pretrial Services test results indicate that PCP positives increased slightly among adult arrestees during the first 11 months of 2006, with around 10 percent testing PCP positive. Juvenile arrestees were more likely to test positive for marijuana than for any other drug. The percentages of juveniles testing marijuana positive have remained about the same for the past few years (around 50 percent). While other parts of the country have seen shifts in the use of methamphetamine, use remains low and confined to isolated communities in DC. The percent of students reporting lifetime use of cocaine, marijuana, and methamphetamine in the DC YRBS decreased from 2003 to 2005. Marijuana and cocaine accounted for nearly all of the $26 million worth of drugs seized by Washington/Baltimore High Intensity Drug Trafficking Area (W/B HIDTA) Initiatives in 2006. According to the W/B HIDTA, drugs trafficked in DC generally originate from Mexico, Southeast Asia, Canada, South America, the Netherlands, and Jamaica. They are shipped through California, Texas, Arizona, North Carolina, New York, Atlanta, and Miami. Intelligence indicates that illicit drug trafficking in the W/B HIDTA area is carried out primarily by Mexican, African-American, Caucasian, Vietnamese, Jamaican, and Asian DTOs. Most of these are polydrug organizations. Recent interviews with criminal justice and public health contacts confirm these trends. Preliminary findings show that the biggest concerns among these key contacts are crack, heroin, PCP, and marijuana. New trends noted by these key contacts are blunts laced with amphetamines and other drugs and the increase in gang activity in the Hispanic population. Misuse of pharmaceuticals among adolescents in the District and surrounding areas of Maryland and Virginia were also areas of concern.

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EPIDEMIOLOGIC TRENDS IN DRUG ABUSE: HIGHLIGHTS AND EXECUTIVE SUMMARY

Recent Trends in Drugrelated Emergency Department Visits from DAWN
Elizabeth H. Crane, Ph.D., M.P.H.1 The Drug Abuse Warning Network (DAWN) is a public health surveillance system administered by the Substance Abuse and Mental Health Services Administration’s Office of Applied Studies. DAWN measures morbidity and mortality related to drug use, misuse, and abuse as reflected in emergency department visits and deaths investigated by medical examiners and coroners. The DAWN emergency department (ED) component collects data from a nationally representative sample of general, non-Federal hospitals with 24-hour emergency departments. DAWN collects data on all ED visits related to recent drug use, regardless of the motive for the drug use. All types of drugs— illegal drugs, prescription and over-thecounter pharmaceuticals, dietary supplements, and non-pharmaceutical inhalants— are included. Alcohol, when it is the only drug implicated in the ED visit, is included for patients younger than age 21; when alcohol is in combination with another drug, is included for patients of all ages. DAWN produces annual estimates of drug-related ED visits for the Nation and for a selection of metropolitan areas.
National Estimates

The most frequent drug categories in the nonmedical-use visits included the central nervous system (CNS) agents (51 percent of visits) and psychotherapeutic agents (46 percent of visits). Among the CNS agents, the opiate/opioid pain medications were the most common, implicated in 33 percent of the nonmedical use ED visits. The most frequent type of psychotherapeutic agents were the sedatives used to treat anxiety and sleeplessness (primarily benzodiazepines), which occurred in 34 percent of the nonmedical-use ED visits. Trends From 2004 to 2005, the total number of emergency department visits in the United States increased 2.3 percent. Drug-related ED visits were stable, as were the ED visits that involved drug misuse/abuse. ED visits that involved the nonmedical use of pharmaceuticals increased 21 percent from 2004 to 2005. ED visits involving opiate/opioid pain medications increased 24 percent, and visits involving benzodiazepines increased 19 percent. DAWN is unable to measure the extent to which external factors—such as the overall increase in ED visits, population growth, or an increase in the number of prescriptions written—may have influenced the increase in the ED visits involving nonmedical use of pharmaceuticals.
Metropolitan Areas

In 2005, an estimated 816,696 drug-related ED visits involved illicit drugs. Alcohol was involved in approximately 493,000 ED visits; most of these (394,000 visits) involved another drug. Almost 600,000 ED visits involved the nonmedical use of pharmaceuticals (prescription and over-thecounter drugs and dietary supplements).
1

Rates2 of drug-related ED visits for 2005 were calculated for the Boston, Denver, Miami (Dade County), New York City (5 boroughs), Phoenix, San Diego, San Francisco, and Seattle metropolitan areas. The rates demonstrate the variability of drugrelated ED visits both within and between metropolitan areas.
2

Dr. Crane is affiliated with the Office of Applied Studies (OAS), Substance Abuse and Mental Health Services Administration (SAMHSA).

Rates were calculated using the 2004 intercensal estimates of population.

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Recent Trends in Drug-related Emergency Department Visits from DAWN

Illicit Drugs

Among the illicit drugs, rates for cocaine-related ED visits ranged from 31 visits per 100,000 population in San Diego to 472 visits per 100,000 in Miami-Dade. Boston, Detroit, New York City, San Francisco, and Seattle all had rates exceeding 190 visits per 100,000 population. Heroin rates were lowest in the metropolitan areas in the Mountain and Southwest regions (29, 31, and 33 visits per 100,000 population in San Diego, Phoenix, and Denver respectively) and highest in New York City (174 visits per 100,000) and Boston (162 visits per 100,000). The rates of marijuana in drug-related ED visits ranged from 46 visits per 100,000 population in San Diego to 185 visits per 100,000 in Miami-Dade. The metropolitan areas located in the West and Mountain regions had much higher rates of illicit stimulants (methamphetamine and amphetamines) than metropolitan areas in the East and Midwest. San Francisco had the highest rates of stimulant-related ED visits in 2005 (240 visits per 100,000 population) followed by Phoenix (134), Seattle (128), San Diego (94) and Denver (71). In comparison, the rates in Boston, Detroit, Miami-Dade, and New York City were less than 9 per 100,000 population.

100,000 population for ED visits involving alcohol with another drug. In San Diego, the rate was 69 visits per 100,000. MiamiDade, San Francisco, and New York City had rates in excess of 250 visits per 100,000 population. Nonmedical use of Pharmaceuticals The rates of ED visits involving the nonmedical use of pharmaceuticals ranged from 127 visits per 100,000 population in San Diego to 264 visits per 100,000 in Seattle. Four metropolitan areas—Boston, Detroit, San Francisco and Seattle—had rates exceeding 200 visits per 100,000 population.

In 9 metropolitan areas, the rate of ED visits involving the nonmedical use of opiates/opioids ranged from 19 visits per 100,000 in Miami to 104 visits per 100,000 in Seattle. In Boston, oxycodone was the most frequently reported opiate/opioid; in Detroit, hydrocodone was the most frequently reported. Methadone stood out in New York City, San Francisco, and Seattle. Methadone is increasingly used to treat pain as well as for opiate replacement therapy, but DAWN data cannot distinguish which type of methadone was involved. If multiple drugs are involved in the ED visit, methadone may be routinely documented in the medical record, but without enough detail to distinguish whether the methadone specifically was related to the ED visit.

Alcohol All of the metropolitan areas except San Diego had rates higher than 100 visits per

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EPIDEMIOLOGIC TRENDS IN DRUG ABUSE: HIGHLIGHTS AND EXECUTIVE SUMMARY

Estimated Number of Drug-Related ED Visits in the United States: 2005 Substance Illicit drugs Alcohol1 Alcohol-in-combination Nonmedical use of pharmaceuticals
1

Estimate 816,696 (CI: 666,947 to 966,446) 492,655 (CI: 424,660 to 560,649) 394,224 (CI: 331,964 to 456,485) 598,542 (CI: 486,771 to 710,314)

2004 vs. 2005 No change No change No change +21percent

Includes all ED visits where alcohol was involved with at least one other drug, and alcohol-only visits for patients under age 21. SOURCE: DAWN, OAS, SAMHSA

Percentages of Types of Drug-Related ED Visits in the United States: 2005
Seeking detox Suicide attempt 7% 5% Other 33% Accidental ingestion 2%

Malicious poisoning 0% Overmedication 10% Underage drinking 4%
SOURCE: DAWN. OAS, SAMHSA

Adverse reaction 39%

Estimated Number of ED Visits for Selected Illicit Drugs in the United States: 2005
Cocaine Alcohol 1 Marijuana Heroin Stimulants PCP Ecstasy
1

448,481 492,655 242,200 164,572 138,950 7,535 10,752

Includes all ED visits where alcohol was involved with at least one other drug, and alcohol-only visits for patients under age 21. SOURCE: DAWN. OAS, SAMHSA

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Recent Trends in Drug-related Emergency Department Visits from DAWN

Estimated Number of ED Visits for Nonmedical Use of Pharmaceuticals in the United States: 2005
Opiates/opioids Benzodiazepines Antidepressants Muscle relaxants
SOURCE: DAWN, OAS, SAMHSA

196,225 172,388 61,023 31,757

ED Visits Per100,000 Population1 Involving Cocaine, Heroin, Marijuana, and Stimulants, by Area: 2005
500 450 400 350 300 250 200 150 100 50 0 Boston Denver Detroit Miami-Dade New York City Phoenix San Diego San Fran. Seattle Cocaine Heroin Marijuana Stimulants

Substance Cocaine Heroin Marijuana Stimulants
1

Boston 193 162 106 8

Denver 125 33 68 71

Detroit 198 94 95 7

MiamiDade 472 112 185 9

New York City 283 174 93 4

Phoenix 83 31 68 134

San Diego 31 29 46 94

San Francisco 291 128 86 240

Seattle 274 139 111 128

Rates for metropolitan areas were calculated using the 2004 intercensal population estimates. SOURCE: DAWN, OAS, SAMHSA

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EPIDEMIOLOGIC TRENDS IN DRUG ABUSE: HIGHLIGHTS AND EXECUTIVE SUMMARY

ED Visits Per 100,000 Population1 Involving Nonmedical Use of Selected Opiates/Opioids, by Area: 2005
40 35 30 25 20 15 10 5 0 Boston Denver Detroit Miami-Dade New York City Phoenix San Diego San Fran. Seattle Hydrocodone Methadone Oxycodone

Substance Hydrocodone Methadone Oxycodone
1

Boston 8 17 34

Denver 12 7 13

Detroit 23 9 6

MiamiDade 2 2 7

New York City 3 32 4

Phoenix 14 8 19

San Diego 12 4 5

San Francisco 19 28 12

Seattle 13 36 24

Rates for metropolitan areas were calculated using the 2004 intercensal population estimates. SOURCE: DAWN, OAS, SAMHSA

ED Visits Per 100,000 Population1 Involving Alcohol,2 by Area: 2005 Substance Alcohol In combination
1 2

Boston 271 205

Denver 184 134

Detroit 171 148

MiamiDade 280 264

New York City 281 251

Phoenix 140 113

San Diego 95 69

San Francisco 310 252

Seattle 227 193

Rates for metropolitan areas were calculated using the 2004 intercensal population estimates. Includes all ED visits where alcohol was involved with at least one other drug, and alcohol-only visits for patients under age 21. SOURCE: DAWN, OAS, SAMHSA

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Appendices

APPENDIX A
Total Admissions, by Primary Substance of Abuse and CEWG Area: 2005–2006 Cocaine/ Crack Other Opiates FY 2006 Boston Cincinnati Detroit San Francisco Arizona
2

Area

Alcohol1

Heroin

Marijuana

Stimulants

Other Drugs

Total

6,274 1,100 1,791 2,251 22,191

1,419 985 2,442 2,314 4,011

8,975 460 2,261 3,309 3,027

652 230 95

501 730 1,127 843

31 19 NR 3 1,260 9,298

246 247 14 145 1,358

18,098 3,771 7,730 10,122 49,587

514 1H 2006

9,218

Atlanta Baltimore Broward County (Sample)4 Denver Mpls./St. Paul New York City St. Louis Seattle Hawaii Texas

1,430 5,006 1,571 2,246 4,694 10,674 1,297 2,074 638 6,798

1,506 2,211 949 933 1,388 8,346 1,663 944 193 7,458

214 7,055 451 367 560 10,918 830 856 107 2,657

NR 949 382 192 391 260 100 265 NR 1,527 CY 2006

920 2,323 336 1,534 1,836 7,915 1,619 1,012 864 6,352

339 49 24 864 806 89 257 707 1,656 3,808

NR 198 360 81 106 890 685 148 181 669

4,409 17,791 4,073 6,217 9,781 39,092 6,451 6,006 3,639 29,269

Maine

5,519

764

1,007

5

2,282 FY 2005

1,169

49

122

10,912

Chicago

12,158

16,845

33,662

685 CY 2005

9,338

174

2,755

75,617

Los Angeles Philadelphia San Diego
1

8,308 3,385 2,576

8,418 4,695 860

9,997 3,107 2,507

510 492 232

7,681 3,120 1,599

13,033 39 5,243

1,328 2,224 102

49,275 17,062 13,119

Includes alcohol-in-combination with other drugs in Atlanta; other areas include alcohol-only or combine alcohol-only and alcoholin-combination. 2 Represents 65–75 percent of the data for FY 2006. 3 NR=Not Reported 4 Represents nine programs in Broward County that serve 51.5 percent of the county admissions. 5I Includes morphine. SOURCES: June 2006 and January 2007 State and local reports

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APPENDIX B-1
DAWN ED Samples and Reporting Information, by CEWG Area: January–June 2006 Total EDs in DAWN Sample 37 78 15 30 22 43 19 26 63 27 17 19 24 No. of EDs Reporting per Month: Completeness of Data (%) ≥90% <90% 21–22 1–2 24–27 2–5 6–7 0 13–18 1–4 4–6 0–2 9–13 1–5 5–9 0–3 7–8 1–2 25–32 5–6 10–15 0–3 7–8 0–1 7–10 0–3 10–11 0–1 No. EDs Not Reporting 13–15 48–50 8–9 10–14 15 29 10–11 16–17 26–33 12–14 9 9–10 12–13

CEWG Area Boston Chicago Denver Detroit Ft. Lauderdale Houston Miami-Dade County Mpls./St. Paul New York City Phoenix San Diego San Francisco Seattle

SOURCE: DAWN Live!, OAS, SAMHSA, updated 11/17–11/20, 2006

APPENDIX B-2
Numbers of Cocaine, Heroin, Methamphetamine (MA), Marijuana (MJ), Methylenedioxymethamphetamine (MDMA), Phencyclidine (PCP), and Lysergic Acid Diethylamide (LSDM) ED Reports in 13 CEWG Areas (Unweighted1): January–June 2006 CEWG Area Boston Chicago Denver Detroit Ft. Lauderdale Houston Miami-Dade Mpls./St. Paul New York City Phoenix San Diego San Francisco Seattle
1

Cocaine 2,273 4,315 1,179 3,655 2,196 2,145 3,153 1,311 7,068 958 342 1,637 2,748

Heroin 1,981 3,336 340 1,793 273 95 602 401 3,807 412 371 578 1,255

MA 39 35 327 13 51 80 16 251 51 821 638 500 722

MJ 1,007 1,555 653 1,466 1,120 1,204 1,321 1,265 2,714 636 432 378 1,001

MDMA 72 67 41 101 51 97 47 63 90 30 29 62 72

PCP 13 35 13 5 4 200 4 19 186 21 16 39 43

LSD 10 6 14 13 10 13 15 28 15 8 7 28 26

All DAWN cases are reviewed for quality control and, based on review, may be corrected or deleted. Therefore, these data are subject to change. SOURCE: DAWN Live!, OAS, SAMHSA, updated 11/17–11/20, 2006

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Participants

National Institute on Drug Abuse Community Epidemiology Work Group Meeting Participant List
January 17–19 Meeting and/or Telephone Conference Calls
Cynthia L. Arfken, Ph.D. Associate Professor Psychiatry and Behavioral Neurosciences Wayne State University 2761 East Jefferson Detroit, MI 48207 Phone: 313-993-3490 Fax: 313-993-1372 E-mail: carfken@med.wayne.edu Erin Artigiani, M.A. Deputy Director for Policy Policy and Governmental Affairs Coordinator, Maryland Drug Early Warning System University of Maryland Center for Substance Abuse Research Suite 501 4321 Hartwick Road College Park, MD 20740 Phone: 301-405-9794 Fax: 301-403-8342 E-mail: erin@cesar.umd.edu Caleb Banta-Green, M.P.H., M.S.W. Research Scientist Alcohol and Drug Abuse Institute University of Washington Suite 120 1107 N.E. 45th Street Seattle, WA 98105 Phone: 206-685-3919 Fax: 206-543-5473 E-mail: calebbg@u.washington.edu George Beschner, M.S.W. Project Director MasiMax Resources, Inc. Suite 175 1375 Piccard Drive Rockville, MD 20850 Phone: 240-683-1757 Fax: 301-926-3156 E-mail: gbeschner@masimax.com Patricia Brundage, Ph.D. Pharmacologist Drug and Chemical Evaluation Section Office of Diversion Control Drug Enforcement Administration 2401 Jefferson Davis Highway Alexandria, VA 22301 Phone: 202-307-7294 Fax: 202-353-1263 E-mail: patricia.m.brundage@usdoj.gov M. Fe Caces, Ph.D. Office of National Drug Control Policy Room 534 750 17th Street, N.W. Washington, DC 20503 Phone: 202-395-3173 Fax: 202-395-6729 E-mail: maria_fe_caces@ondcp.eop.gov Leslie Clinkenbeard Epidemiologist Substance Abuse Services Prevention Oklahoma Department of Mental Health and Substance Abuse Services 1200 N.E. 13th P.O. Box 53277 Oklahoma City. OK 73152-3277 Phone: 405-522-1661 Fax: 405-522-3767 E-mail: lclinkenbeard@odmhsas.org Wilson M. Compton, M.D., M.P.E. Director Division of Epidemiology, Services and Prevention Research National Institute on Drug Abuse National Institutes of Health Neuroscience Center, Room 5153 6001 Executive Boulevard, MSC-9589 Bethesda, MD 20892-9589 Phone: 301-443-6504 Fax: 301-443-2636 E-mail: wcompton@nida.nih.gov

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Elizabeth Crane, Ph.D., M.P.H. Service Fellow Drug Abuse Warning Network Substance Abuse and Mental Health Services Administration Room 7-1044 1 Choke Cherry Road Rockville, MD 20850 Phone: 240-276-1275 Fax: 240-276-1260 E-mail: elizabeth.crane@samhsa.hhs.gov Samuel J. Cutler Program Manager Coordinating Office for Drug and Alcohol Abuse Programs Philadelphia Office of Behavioral Health Suite 800 1101 Market Street Philadelphia, PA 19107-2908 Phone: 215-685-5414 Fax: 215-685-5427 E-mail: sam.cutler@phila.gov Mark Dennis Conference Manager MasiMax Resources, Inc. Suite 175 1375 Piccard Drive Rockville, MD 20850 Phone: 240-631-3952 Fax: 301-926-3156 E-mail: mdennis@masimax.com Brian J. Dew, Ph.D., L.P.C. Assistant Professor Department of Counseling and Psychological Services Georgia State University 640 Glen Iris Drive, #510 Atlanta, GA 30308 Phone: 404-651-3409 Fax: 404-651-1160 E-mail: bdew@gsu.edu Ilene L. Dode, Ph.D. Chief Executive Officer Emeritus EMPACT-Suicide Prevention Center, Inc. 2528 East Geneva Drive Tempe, AZ 85282 Phone: 480-620-4499 Fax: 480-720-9877 E-mail: idode@aol.com

Daniel P. Dooley Boston Public Health Commission 1010 Massachusetts Avenue Boston, MA 02118 Phone: 617-534-2360 Fax: 617-534-2422 E-mail: ddooley@bphc.org Marya Hynes Dowell, M.H.S. Drug Abuse Research Specialist CICAD Inter-American Observatory on Drugs (OID) OAS, Inter-American Drug Abuse Control Commission 1889 F Street, N.W. Washington, DC 20005 Phone: 202-458-6119 Fax: 202-458-3658 E-mail: mhynes@oas.org Carol L. Falkowski Director Research Communications Hazelden Foundation Butler Center for Research 15245 Pleasant Valley Road, Box 11 Center City, MN 55012-0011 Phone: 651-213-4566 Fax: 651-213-4344 E-mail: cfalkowski@hazelden.org Robert J. Graff, Ph.D. Staff Epidemiologist Substance Abuse Program, Division of Behavioral Health Idaho Department of Health and Welfare P.O. Box 83720 Boise, ID 83720-0036 Phone 208-334-6513 Fax 208-332-7330 E-mail: graffr@dhw.idaho.gov James N. Hall Director Center for the Study and Prevention of Substance Abuse Nova Southeastern University Up Front Drug Information Center Suite 215 12360 Southwest 132nd Court Miami, FL 33186 Phone: 786-242-8222 Fax: 786-242-8759 E-mail: upfrontin@aol.com

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Participants

Alison Hamilton, Ph.D. Assistant Research Anthropologist Integrated Substance Abuse Programs University of California, Los Angeles Suite 200 1640 S. Sepulveda Boulevard Los Angeles, CA 90025 Phone: 310-267-5421 Fax: 310-473-7885 Email: alisonh@ucla.edu Leigh Henderson, Ph.D. Project Manager Integrated Data for Substance Abuse Treatment Services Synectics for Management Decisions, Inc. 3001 Guilford Avenue Baltimore, MD 21218-3926 Phone: 410-235-3096 Fax: 703-528-8990 E-mail: leighh@smdi.com Kenneth Hoffman, M.D., M.P.H. Medical Officer Center for Substance Abuse Treatment Division of Pharmacologic Therapies Substance Abuse and Mental Health Services Administration Room 21079 1 Choke Cherry Road Rockville, MD 20857 Phone: 240-276-2701 Fax: 240-276-2710 E-mail: kenneth.hoffman@samhsa.hhs.gov Tamara Hoxworth, Ph.D. Research Analyst Alcohol and Drug Abuse Division Colorado Department of Human Services Building KA 4055 South Lowell Boulevard Denver, CO 80236-3120 Phone: 303-866-7497 Fax: 303-866-7481 E-mail: tamara.hoxworth@state.co.us Benton Johnston, Intelligence Specialist U.S. Department of Justice 1433 W. Loop South, #600 Houston, TX 77022 Phone: 713-693-3000

Doug Kershaw Senior Research Associate Department of Healthcare Sciences University of Texas Southwestern Medical Center 400 S. Zang Dallas, TX 76051 Phone: 214-645-7329 Fax: 214-645-7303 E-mail: doug.kershaw@utsouthwestern.edu Rozanne Marel, Ph.D. New York State Office of Alcoholism and Substance Abuse Services 501 Seventh Avenue, 9th Floor New York, NY 10018 Phone: 646-728-4605 Fax: 646-728-4685 E-mail: rozannemarel@oasas.state.ny.us Jane C. Maxwell, Ph.D. Research Professor Center for Social Work Research University of Texas at Austin Suite 335 1717 West 6th Street Austin, TX 78703 Phone: 512-232-0610 Fax: 512-232-0616 E-mail: jcmaxwell@sbcglobal.net John A. Newmeyer, Ph.D. Epidemiologist Haight-Ashbury Free Clinics, Inc. 2nd Floor 612 Clayton Street San Francisco, CA 94117 Phone: 415-710-3632 Fax: 415-864-6162 E-mail: jnewmeyer@aol.com Moira P. O'Brien, M. Phil. Program Director Research on Emerging and Current Trends Epidemiology Research Branch Division of Epidemiology, Services and Prevention Research National Institute on Drug Abuse National Institutes of Health Room 5153, MSC-9589 6001 Executive Boulevard Bethesda, MD 20892-9589 Phone: 301-402-1881 Fax: 301-443-2636 E-mail: mobrien@nida.nih.gov

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EPIDEMIOLOGIC TRENDS IN DRUG ABUSE: HIGHLIGHTS AND EXECUTIVE SUMMARY

Lawrence Ouellet, Ph.D. Research Associate Professor Division of Epidemiology and Biostatistics Community Outreach Intervention Projects School of Public Health, MC 923 University of Illinois at Chicago 1603 West Taylor Street Chicago, IL 60612-4394 Phone: 312-355-0145 Fax: 312-996-1450 E-mail: ljo@uic.edu Robin Pollini, Ph.D., M.P.H. University of California, San Diego School of Medicine 9500 Gilman Drive, MS 0622 San Diego, CA 92093 Phone: 858-534-0710 Fax: 858-534-7053 E-mail: rpollini@ucsd.edu Albert Reeder Project Manager School of Social Work – Drug and Alcohol Offender Education The University of Texas at Austin Suite #335 1717 West 6th Street Austin, Texas 78703 Phone: 512-232-0636 Fax: 512-232-0613 E-mail: albert.reeder@mail.utexas.edu Beth A. Rutkowski, M.P.H. Associate Director of Training/Epidemiologist ATTC/NIDA Liaison Integrated Substance Abuse Programs University of California, Los Angeles Suite 200 1640 South Sepulveda Boulevard Los Angeles, CA 90025 Phone: 310-445-0874, ext. 376 Fax: 310-312-0538 E-mail: finnerty@ucla.edu Jan Scaglione, M.T., Pharm.D., D.A.B.A.T. Cincinnati Drug and Poison Information Center ML-9004 3333 Burnet Avenue Cincinnati, OH 45229 Phone: 513-636-5060 Fax: 513-636-5069 E-mail: jan.scaglione@cchmc.org

Nina G. Shah, M.S. Substance Abuse Epidemiologist Office of Epidemiology New Mexico Department of Health 1190 St. Francis Drive, N1310 Santa Fe, NM 87502 Phone: 505-476-3607 Fax: 505-827-0013 E-mail: nina.shah@doh.state.nm.us Marcella H. Sorg, R.N., Ph.D., D.-A.B.F.A. Research Associate Margaret Chase Smith Policy Center University of Maine 5715 Coburn Hall Orono, ME 04469 Phone: 207-581-2596 Fax: 207-581-1266 E-mail: marcella.sorg@umit.maine.edu James Topolski, Ph.D. Research Assistant Professor and Director Missouri Institute of Mental Health University of Missouri-Columbia School of Medicine 5400 Arsenal Street St. Louis, MO 63139 Phone: 314-877-6413 Fax: 314-877-6477 E-mail: jim.topolski@mimh.edu Boyd E. Wilmoth, M.S. Research Analyst Idaho Health and Welfare/Substance Abuse 450 W. State Street, 3rd Floor P.O. Box 83720 Boise, ID 83720-0036 Phone: 208-334-6506 Fax: 208-334-0667 E-mail: milmothb@idhw.state.id.us D. William Wood, M.P.H., Ph.D. Professor and Chair Department of Sociology University of Hawaii at Manoa Saunders Hall 247, 2424 Maile Way Honolulu, HI 96822 Phone: 808-956-7693 Fax: 808-956-3707 E-mail: dwwood@hawaii.rr.com

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NIH Publication No. 07-6200 August 2007